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

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment supported crown (D6058) provided on January 27, 2020.
You asked the Plan to pay for the custom fabricated abutment and abutment supported crown. You say that you would like reconsideration because you have had extensive dental work and the Plan's denial of services are not consistent. The Plan denied your request. The Plan says services rendered by an out-of-network dentist are 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. Specifically, your contract with the Plan requires the use of network dentists. This dentist is not in-network with the Plan; therefore, you are responsible for payment. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment supported crown (D6058) provided on January 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on December 11, 2020.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed service cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the documentation in the enrollee's medical documentation. 

We looked at the file and the rules. In this case, there are insufficient medical records to show that the enrollee's treating physician ordered the testing to treat a specific medical problem or determine a specific diagnosis. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on December 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider on March 15, 2021.

You asked the Plan to pay for the laboratory test. You say that you perform drug monitoring at the request of the ordering physicians who sends the authorizing requisition. You say that payment should be allowed. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was not approved in advance.

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 laboratory test provided by an out-of-network provider on March 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty manual wheelchair with non-standard seat.

You asked the Plan to pre-approve heavy-duty manual wheelchair with seat. You say that your wheelchair is too heavy and you cannot go up or down stairs or go outside with it. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because you are able to ambulate well within the home and this appears to be for use primarily outside of the home.

The Plan follows Medicare rules. Medicare rules state that a heavy-duty manual wheelchair is only covered if certain criteria are met.

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 heavy-duty manual wheelchair with seat. Our reviewer says that you do not meet the Medicare criteria for the requested heavy-duty manual wheelchair with seating. Our physician reviewer found the documentation does show that you have a mobility limitation, but it is not clear that it significantly impairs your ability to participate in one or more mobility-related activities of daily living such as toileting, feeding, grooming, and bathing in customary locations in the home. The documentation does not show that your mobility limitation cannot be sufficiently and safely resolved by the use of an appropriate walker. While you may be able to use the requested wheelchair, the documentation does not support that use of this wheelchair would significantly improve your mobility-related activities of daily living. As such, the wheelchair and seating are not 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 heavy-duty manual wheelchair. Because the heavy-duty manual wheelchair is not covered, the attached seating would also not be covered. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty manual wheelchair with non-standard seat.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image
(D0230) and the intraoral - periapical first radiographic image (D0220) received February 10, 2021.

You asked the Plan to pay for the intraoral radiographic images. You say that you were not told that these xrays
would not be covered. The Plan denied your request. The Plan says there is no coverage for intraoral
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 intraoral -
periapical each additional radiographic image (D0230) and the intraoral - periapical first radiographic image
(D0220) received February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5261, V5267, S9999) purchased January 18, 2021 from a non-Plan hearing vendor.
You asked the Plan to pay for the hearing aids. You say that the hearing aid should be covered by the Plan. The Plan denied your request. The Plan says hearing aids purchased outside of the Plan's hearing vendor network are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only purchased from a Plan hearing vendor. We looked at the file, and the Plan's rules. The Plan does not cover hearing aids purchased outside of the Plan's hearing vendor network. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261, V5267, S9999) purchased January 18, 2021 from a non-Plan hearing vendor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on September 7, 2020.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the records did not include a physician order or lab requisition showing the intent for the testing.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We looked at the file and the rules. In this case, there is no order or medical records to show that the results of the testing would be used in the management of a specific medical problem. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on September 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) and the prophylaxis (D1110) received February 17, 2021 from the non-participating provider.

You asked the Plan to pay for the dental services. You say that you did not know Avesis administered your dental benefit. The Plan denied your request. The Plan says services are only covered when received by a participating provider.

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 when received from a non-participating provider. Therefore, we decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) and the prophylaxis (D1110) received February 17, 2021 from the non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on February 10, 2021, by an
OON provider.

You asked the Plan to pay for lab test. You say that this testing meets the requirements for coverage. The Plan
denied your request. The Plan says the denial of payment for this testing is correct, because this provider is outof-
network with the Plan and the ordering provider is also out-of-network with the Plan.

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 laboratory testing provided on February 10, 2021,
by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye examination (92014) provided on December 8, 2020.

You asked the Plan to pay for an eye examination. You say that you thought the provider was in-network and
you want the Plan to pay for the service at issue. The Plan denied your request. The Plan says you are not
covered for this service when seen by an out-of-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 the Plan's network providers are utilized.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of an eye examination have not been met. Specifically, services were provided by an out-of-network
provider. The Plan has contracted providers available to provide these services. 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
an eye examination (92014) provided 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 March 22, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 27447 is 1. You billed 2 units of this code, exceeding the MUE. 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 March 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on January 4, 2021.
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says in most cases, care received from an out-of-network provider will not be covered, with the following three exceptions: emergency care or urgently needed services, Medicare covered medical care that the providers in our network cannot provide, and dialysis services at a Medicare certified dialysis facility when you are temporarily outside the Plan's service area. A prior authorization is required if you are seeking non-emergency out-of-network care. Additionally, routine vision services are offered through the Plan's vision provider.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided through the Plan's vision provider. We looked at the file and the Plan's rules. The file shows that they eyeglasses were not provided by the Plan's vision provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on
January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the nine extractions (41899 x9) and anesthesia for intraoral procedures
(00170 x2) provided on February 3, 2021.

You asked the Plan to pay for the extractions and anesthesia. You say that you believe these services should be
covered under your medical benefits, and not dental. The Plan denied your request. The Plan says that the
treating provider opted out of Medicare.

Medicare generally does not cover dental services. The Plan follows the same rule. The extraction of teeth to
prepare the jaw for radiation treatment of neoplastic disease is also covered. This is an exception to the
requirement that to be covered, a noncovered procedure or service performed by a dentist must be an incident
to and an integral part of a covered procedure or service performed by the dentist. Ordinarily, the dentist
extracts the patient's teeth, but another physician, e.g., a radiologist, administers the radiation treatments.

The Plan denied the extractions and anesthesia stating that the treating provider has opted out of Medicare.
According to the Centers for Medicare and Medicaid Services (CMS) Opt-Out Affidavit list, the provider at
issue is not a Medicare opt out provider. The EOC is clear that services rendered by out-of-network providers
who do not participate with Medicare are covered. The documentation shows that these services were provided
to prepare the jaw for radiation treatments of neoplastic cancer disease, which is covered by the Plan.
Therefore, we decided that the Plan has to pay for the nine extractions (41899 x9) and anesthesia for intraoral
procedures (00170 x2) provided on February 3, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on January 6, 2020.

You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says the place of service on the claim must reflect the location of the enrollee when the specimen was obtained.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We looked at the file and the rules. The submitted claim lists the place of service as an independent lab. The records do not indicate that the enrollee's specimen was taken at an independent lab. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 28, 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 claim is a duplicate.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. 

We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 laboratory services rendered on December 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic pulpotomy (excluding final restoration) (D3220), the limited oral evaluation - problem focused (D0140), the unspecified preventive procedure, by report (D1999) and the intraoral - periapical first radiographic image (D0220) received February 10, 2021.

You asked the Plan to pay for the dental services (D0220, D3220, D0140, D1999). You say that you should only be responsible for 50% of the charges. The Plan denied your request. The Plan says the requested services are either not covered, or in excess of what is covered under your supplemental benefit.

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 or are in excess of what is covered under this benefit.

There is no coverage for therapeutic pulpotomy (D3220) or unspecified preventive procedure, by report (D1999). The Plan limits coverage of intraoral periapical radiographic images (D0220) to one procedure per calendar year. The Plan has already agreed to cover one intraoral radiographic image procedure on February 9, 2021. The remaining intraoral periapical radiographic image procedure is in excess of your benefit and is your responsibility. The Plan offers coverage for limited oral evaluation - problem focused (D0140). When received out-of-network you are responsible for 50% of the cost (50% coinsurance) of the limited oral evaluation. If you see an out-of-network dentist, the coinsurance level will apply to the average negotiated in-network fee schedule (INFS) in your area. The Plan's negotiated INFS for the limited oral evaluation is $33.00. You are responsible for 50% of this cost ($16.50). In addition, your contract with the Plan states that you may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider. The Plan has provided coverage in accordance with the contract.

Therefore, we decided that the Plan does not have to pay for the therapeutic pulpotomy (excluding final restoration) (D3220), the limited oral evaluation - problem focused (D0140), the unspecified preventive procedure, by report (D1999) and the intraoral - periapical first radiographic image (D0220) received February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on March 8, 2021.

You asked the Plan to pay for an eye refraction. You say that you want the Plan to pay for the service. The Plan
denied your request. The Plan says the service at issue is not a covered benefit when performed during a
medical eye examination.

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 performed as part of a routine eye examination.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of an eye refraction have not been met. Specifically, eye refraction is only covered by the Plan when
it is performed as part of a routine screening by a participating provider. This service was performed for
medical vision purposes, and therefore is not a covered benefit. Therefore, we decided that the Plan does not
have to pay for an eye refraction (92015) provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 3, 2020.

You asked the Plan to pay for the dental service. You say that your dentist advised that your tooth needed to be removed rather than a filling. You say that you did not agree with that. You say that you went for a second opinion. You say that this dentist could save your tooth. You also say that you believe that the second opinion was warranted. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit has been exceeded.

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 and comprehensive oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on August 13, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 3, 2020.