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

We decided that the Plan does not have to pay for the laboratory services coded 86141, 83090, 82607, 86328, 84270, 84403, 84481, 84550, 85025, 82746, 83615, 84144, 84202, 82533, 82627, 82670, and 80053 provided on July 14, 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 billed are not supported by the documentation.
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 find that CPT codes 86141, 83090, 82607, 86328, 84270, 84403, 84481, 84550, 85025, 82746, 83615, 84144, 84202, 82533, 82627, 82670, and 80053 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 86141, 83090, 82607, 86328, 84270, 84403, 84481, 84550, 85025, 82746, 83615, 84144, 84202, 82533, 82627, 82670, and 80053 provided on July 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy provided on February 18, 2021.
You asked the Plan to pay for endodontic therapy. You say that you assumed your financial responsibility for
the oral surgery would be $400. You say that the treatment for your illness or injury should be covered as
outpatient care. The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for endodontic therapy provided on
February 18, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and Monovisc first.
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 Euflexxa. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is diagnosed with osteoarthritis of the knee. The enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered or that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, Euflexxa is not approved as step criteria have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the thoracolumbosacral orthosis provided on March 31, 2021.
You asked the Plan to pay for the thoracolumbosacral orthosi. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation is missing required information.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file
shows that the documentation submitted did not include a valid proof of delivery or a delivery ticket. The
record shows that the Plan made several attempts to obtain the necessary documentation without success.
Therefore, we decided that the Plan does not have to pay for the thoracolumbosacral orthosis provided on
March 31, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on
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 rendered are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that tests that include more than 5 viral pathogens are non-covered. We looked at the file and Medicare rules. Review of the file shows that the services rendered included more than 5 viral pathogens. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder orthosis (L3670) and miscellaneous DME supply (A9900) provided September 21, 2020.
You asked the Plan to pay for the orthosis and miscellaneous item. You say that the medical records provided support the necessity of the items in dispute. The Plan denied your request. The Plan says there is evidence of misrepresented services.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid proof of delivery, or relevant medical records which support medical
necessity for the supplies provided in this case. Specifically, the proof of delivery documentation did not
include an order number or itemization to indicate the specific supplies. Also, the Plan was unable to discover
any evidence of an established relationship between the enrollee and the ordering physician. The record shows
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we
decided that the Plan does not have to pay for the shoulder orthosis (L3670) and miscellaneous DME supply
(A9900) provided September 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330), surgical extraction (D7210), first 15 minutes of deep sedation/general anesthesia (D9222), each subsequent 15 minute increment of deep sedation/general anesthesia (D9223), consultation (D9310), and therapeutic parenteral drug (D9610) provided from August 7, 2020, to August 28, 2020.
You asked the Plan to pay for the panoramic x-ray, surgical extraction, deep sedation/general anesthesia, consultation, and therapeutic parenteral drug. You say that the provider advised that these services would be covered prior to these services being rendered. The Plan denied your request. The Plan says these services are 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. The only extractions that are covered by your plan are simple extractions. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330), surgical extraction (D7210), first 15 minutes of deep sedation/general anesthesia (D9222), each subsequent 15 minute increment of deep sedation/general anesthesia (D9223), consultation (D9310), and therapeutic parenteral drug (D9610) provided from August 7, 2020, to August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-prescription drugs provided on May 29, 2020.
You asked the Plan to pay for the non-prescription drugs. You say that you feel these drugs should be covered. The Plan denied your request. The Plan says the items received are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the non-prescription drugs is an OTC item. Therefore, we decided that the Plan does not have to pay for the non-prescription drugs provided on May 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses deluxe frames (V2025), progressive lenses (V2781), and miscellaneous vision item or service (V2799) provided March 20, 2021.
You asked the Plan to pay for the routine eyeglasses. You say that you would like this claim processed under your vision benefits. The Plan denied your request. The Plan says routine eyewear is not covered when purchased out-of-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 purchased at a network optical provider. We looked at the file and the Plan's rules. In this case you purchased routine eyeglasses from an out-of-network provider. Your vision benefits do not include out-of-network coverage. We found no exception that would require the Plan to cover the routine eyeglasses provided out-of-network. Based on this information, we decided that the Plan's rules for coverage of the routine eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses deluxe frames (V2025), progressive lenses (V2781), and miscellaneous vision item or service (V2799) provided March 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral periapical radiographic images (D0220, D0230)
provided on March 3, 2021.
You asked the Plan to pay for intraoral periapical radiographic images. You say that the services at issue should
be covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 intraoral
periapical radiographic images (D0220, D0230) provided on March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the thoracic-lumbar-sacral orthosis (L0457) provided March 9, 2021.
You asked the Plan to pay for the orthosis. You say that please review this claim due to the current COVID-19 pandemic guidelines and reconsider accordingly. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician as required per CMS guidelines and the documentation submitted did not sufficiently document the enrollee's medical condition to support medical necessity.
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 the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that meets the requirements for Medicare coverage for the requested thoracic-lumbar-sacral orthosis (L0457). Records do not clearly document an established relationship between the prescribing provider and the enrollee or that the visit was conducted as a telehealth visit due to safety concerns related to COVID-19 (as the vendor in this case has argued). 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the thoracic-lumbar-sacral orthosis (L0457) provided March 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical radiographic images (D0220, D0230) received March 11, 2021.
You asked the Plan to pay for the periapical radiographic images. You say that the requested services should be covered by the Plan. The Plan denied your request. The Plan says there is no coverage for radiographic images.
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 periapical radiographic images (D0220, D0230) received March 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on September 25, 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 97110 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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services.
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 physical therapy services rendered on September 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330), maxillary partial denture (D5225), and mandibular partial denture (D5226) provided on January 24, 2020.
You asked the Plan to pay for the panoramic x-ray, maxillary partial denture, and mandibular partial denture. You say that you were advised by your insurance sales agent that you had a $3,000 allowance for dental services in 2020. The Plan denied your request. The Plan says the annual limit allowed by your dental plan for the 2020 benefit year has been paid. The Plan also says that neither you nor your provider contacted the Plan prior to this date of service to verify benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $500 allowance every year for Non-Medicare covered preventive and comprehensive dental services combined. You are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit on February 18, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330), maxillary partial denture (D5225), and mandibular partial denture (D5226) provided on January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacral lateral nerve radiofrequency ablation (RFA).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has low back pain. The use of RFA to the sacral nerves is considered experimental/investigational in nature. The services are not the standard of care and are not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacral lateral nerve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 3, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 February 3, 2021 by an out-of-network (OON) provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy, flexible; with biopsy, single or multiple (45380) provided March 4, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you had a colonoscopy done and the Plan paid 100%. However, there is another claim with a $300 copay for a hospital visit and this must be in error. Your plan pays for 100% coverage for a colonoscopy, and you were not admitted. The Plan denied your request. The Plan says the claim was processed for the diagnostic colonoscopy procedure 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 $300 copayment for each Medicare covered
outpatient surgery or procedure at an outpatient hospital facility or ambulatory surgical center.
You have been asked to pay $300 copayment for the diagnostic service. The diagnostic service falls within the
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers
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 colonoscopy, flexible; with
biopsy, single or multiple (45380) provided March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit rendered on January 14, 2021.
You asked the Plan to waive the copayment for these services. You say that you were charged for a routine physical. The Plan denied your request. The Plan says the copayment 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 $15 copayment per provider, per day for in-network primary care provider (PCP) services.
Review of the file shows that you received PCP services on January 14, 2021. The records show that you received services outside of the scope of an annual physical during the appointment. You have been asked to
pay a $15 copayment for these services. These services fall within the in-network primary care provider (PCP) 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 the office visit rendered on January 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on March 4, 2021.
You asked the Plan to pay for the home visit. You say that the patient is homebound, and this was medically necessary. You say that the claim should be reprocessed. The Plan denied your request. The Plan says in-network providers were 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 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 home visit provided by an out-of-network provider on March 4, 2021.