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

We decided that the Plan does not have to pay for a femur x-ray (73552) provided on September 1, 2019.
You asked the Plan to pay for the x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these codes must be submitted with a modifier of 26 to indicate "professional component" in a Part A stay
The Plan must follow Medicare rules. Medicare rules say that that for services that contain both a technical component and a professional component, the technical component, if any, must be billed by the SNF for its Part A inpatients. We find that CPT code 73552 is not supported in the medical record. Specifically, the record indicates that this member was in an SNF. This means that the technical component of the code is the responsibility of the facility. In this case, the TC is not separately billable, and the CPT code at issue has not been billed with the appropriate modifier to indicate that this was the professional component. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a femur x-ray (73552) provided on September 1, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for noninvasive ear or pulse oximetry (94762)
You asked the Plan to pay for the noninvasive ear or pulse oximetry. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says as CPT code
94762 is a technical component only code, it should be reported by a MAC Part A or B hospital setting.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier
other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the noninvasive ear or pulse oximetry have not been met. Specifically, payment for this service is
the responsibility of the facility. Therefore, we decided that the Plan does not have to pay for noninvasive ear
or pulse oximetry (94762)
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on
September 3, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for outpatient mental health care provided to the enrollee on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve an office visit. You say that this is a continuation of care. The Plan denied
your request. The Plan says there is no network deficiency for these services and alternate network providers
were found.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan says that the continuation of care
program is available if your provider has left the network and you need to complete a course of therapy. It does
not apply for continuing with non-network providers. We found no exception that would require the Plan to
pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office
visit to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation, endodontic therapy, and treatment of root canal obstruction provided by an Endodontist on November 12, 2019. We also decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), four periodontal procedures (D4999 x4), and four gingival irrigations (D4921 x4) provided by an in-network provider on December 9, 2019.
You asked the Plan to pay for the consultation, endodontic therapy, treatment of root canal obstruction, topical application of fluoride varnish, four periodontal procedures, and four gingival irrigations. You say that the out-of-network provider is associated with the dentist the Plan sent you to. You also say that you requested specific items of coverage under your plan before going to the dentist that the Plan selected for you. The Plan denied your request. The Plan says services from a specialist are not covered under your plan. The Plan also says that topical application of fluoride varnish, unspecified periodontal procedure, and gingival irrigation 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 contract clearly states that services provided by a specialist are not a covered dental service. The treating provider from November 12, 2019 was an Endodontist, and therefore, these services are not covered. Topical application of fluoride varnish, unspecified periodontal procedure, and gingival irrigation are also not among those covered under this benefit according to the Plan's contract. The record shows that you were given a treatment plan by your dentist, were informed that the services were not covered, and you accepted the alternative and responsibilities for the treatment. Therefore, we decided that the Plan does not have to pay for the consultation, endodontic therapy, and treatment of root canal obstruction provided by an Endodontist on November 12, 2019. We also decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), four periodontal procedures (D4999 x4), and four gingival irrigations (D4921 x4) provided by an in-network provider on December 9, 2019.
Your complaint about your unhappiness with the Plan 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additional dental implant.
You asked the Plan to pre-approve one additional dental implant. You say that you have attended several dental appointments in order to be assisted with your removable denture. You also say that your denture keeps falling out when you eat or speak. The Plan denied your request. The Plan says a third dental implant 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, endosteal implants are limited to 2 per 5 years. The record shows that you were approved for two implants and your implants benefit has been exhausted. You also have a $2,300 annual maximum benefit each year. The record shows that you have already used $519 of this benefit and only have a remaining amount of $1,781 to use toward covered dental services for the year of 2020. Therefore, we decided that the Plan does not have to pre-approve the additional dental implant.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary to build your strength. The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you are currently undergoing treatment at an acute care hospital (ACH) for aspiration pneumonia. You are not intubated/ventilated. There is no evidence that you require services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring you to the LTACH. You can remain at the current ACH until such time no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a thoracic lumbar-sacral orthosis to be provided by an out of network provider.
You asked the Plan to pre-approve a thoracic lumbar-sacral orthosis from an out of network provider. You say that you have back pain standing and walking. The Plan denied your request. The Plan says they will approve the orthosis from an in-network provider.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the item at issue in this appeal. We found no exception that would require the Plan to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve a thoracic lumbar-sacral orthosis to be provided by an out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit and a stress test
provided by participating providers on December 2, 2019 to December 5, 2019.
You asked the Plan to waive the copayment for a specialist office visit and a stress test. You say that you
shouldn't have to pay for these services because you feel like these services were unnecessary. The Plan denied
your request. The Plan says the correct copayments have been applied.
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 $50
copayment for physician/practitioner services/in-network/specialist and a $225 copayment for outpatient
diagnostic tests/in-network/diagnostic radiology.
You have been asked to pay a $50 copayment for a specialist office visit and a $225 copayment for a stress test.
The total amount you are being asked to pay is $275 ($50 + $225 = $275). A specialist office visit falls within
the physician/practitioner services/in-network/specialist and a stress test falls within the outpatient diagnostic
tests/in-network/diagnostic radiology 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
specialist office visit and a stress test provided by participating providers on December 2, 2019 to December 5,
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hospital bed, total electric (head, foot and height adjustments), with any type side rails, with mattress (E0265).
You asked the Plan to pre-approve electric hospital bed. You say that the full electric bed will help with getting up off the floor and also getting up from a seated position without assistance and it will allow you to maintain independent living. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of electric hospital bed have not been met. The height adjustment feature is a convenience feature. Therefore, we decided that the Plan does not have to pre-approve hospital bed, total electric (head, foot and height adjustments), with any type side rails, with mattress (E0265).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider from November 5, 2019, to November 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
from November 5, 2019, to November 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the repair of a dental implant on tooth #8.
You asked the Plan to pre-approve the repair of a dental implant on tooth #8. You say that you received this
implant while you were on a different plan, but now the implant is damaged. You also say that you are
experiencing a lot of discomfort. The Plan denied your request. The Plan says this service is not a covered
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, any services associated with dental
implants not originally placed by a participating provider are excluded from coverage.
The record shows that you received an implant supported crown on tooth #8 from an out-of-network dentist
while you were enrolled with a different health plan. Therefore, we decided that the Plan does not have to preapprove
the repair of a dental implant on tooth #8.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency care provided to the enrollee
on December 2, 2019.
You asked the Plan to waive the copayment. You say that the enrollee shouldn't be responsible because the
enrollee was misdiagnosed. The Plan denied your request. The Plan says the claim processed 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $120 copayment for each Medicare-covered emergency room visit.
Review of the file show that the enrollee was provided emergency care on December 2, 2019. The enrollee has
been asked to pay a $120 copayment for the services. The services fall within the emergency care 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 emergency care provided to
the enrollee on December 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build-up for tooth #6 (D2950) and root canal for tooth #6 (D3310).
You asked the Plan to pre-approve the dental services. You say that the records should support the necessity of the service in dispute. The Plan denied your request. The Plan says this requested services 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 pre-approve core build-up for tooth #6 (D2950) and root canal for tooth #6 (D3310).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve ophthalmology services. You say that you have a history with this provider.
You say that you would like to continue to see her, The Plan denied your request. The Plan says there is no
network deficiency for these services and alternate network providers were found. 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care
and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
ophthalmology services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve testing blood sugar levels 3 times a day.
You asked the Plan to pre-approve additional testing. You say that if it is approved, it will not increase spending. The Plan denied your request. The Plan says there is not enough evidence to support the need to test 3 times a day.
The Plan follows Medicare rules. Medicare rules say that diabetic test strips are covered under certain medical indications. 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 additional testing. Our physician reviewer found that you are noted to be a diabetic, who takes oral medication to control your diabetes. There is no evidence that your diabetes is poorly controlled, that you are starting new medications to treat your diabetes, or that you are undergoing frequent medication adjustments to treat your diabetes. As such, the request for supplies to test your blood glucose three times a day is not shown to be currently medically necessary or reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional testing have not been met. Therefore, we decided that the Plan does not have to pre-approve testing blood sugar levels 3 times a day.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF)
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network locations 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lens polish coded with V2799 provided on December 24, 2019.
You asked the Plan to pay for the lens polish. You say that The Plan denied your request. The Plan says that your eyewear allowance is exhausted.
Medicare generally does not cover dental services. However, the Plan offers a vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to a $100 allowance for eyewear every 24 months.
We looked at the file and Medicare rules. The file shows that the plan has approved the maximum 24 month benefit of $100 for the requested services. There is no provision in the contract which would require the plan to approve more than this amount. Therefore, we decided that the Plan does not have to pay for the lens polish coded with V2799 provided on December 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental surgery procedure provided on March 15, 2019.
You asked the Plan to pay for the dental surgery procedure. You say that the rendering provider is a subject matter expert, the charges are legitimate and deserve to be paid in full. The Plan denied your request. The Plan says charges for dental and dental related services are not covered under the enrollee's 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 dental surgery procedure provided on March 15, 2019.