Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 4, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 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 physician's services provided on December 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ligation services coded 37606 provided on September 12, 2020.

You asked the Plan to pay for the ligation 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 payable.

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 37606 is ligation; internal or common carotid artery, with gradual occlusion, as with Selverstone or Crutchfield clamp. 

We find that CPT code 37606 is not supported in the medical record. Specifically, this code was billed with modifiers RR, KR, KH, and KX. These modifiers are inappropriate for this code. Based on this information, we decided that Medicare rules for coverage of the ligation services have not been met. Therefore, we decided that the Plan does not have to pay for the ligation services coded 37606 provided on September 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of a CardioMEMS pulmonary artery pressure sensor device.

You asked the Plan to pre-approve the CardioMEMS procedure. You say that this device would be helpful to reduce hospitalization. The Plan denied your request. The Plan says there is insufficient evidence that the requested procedure is clinical useful.

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 the CardioMEMS procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical study is needed to determine the efficacy and safety of this device. It is not clear that the CardioMEMS device is medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee is enrolled in a clinical trial for evidence development. 

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 CardioMEMS procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of a CardioMEMS pulmonary artery pressure sensor device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral surgery procedure, three infiltrations of sustained release therapeutic drugs, comprehensive oral evaluation, and four resin-based composites provided from October 7, 2020, to November 11, 2020 by an OON provider.
You asked the Plan to pay for the oral surgery procedure, therapeutic drugs, comprehensive oral evaluation, and resin-based composites. You say that you believe these services should be covered. The Plan denied your request. The Plan says oral surgery procedure and infiltration of sustained release therapeutic drug are not covered services. The Plan says that your benefits for the resin-based composites have been satisfied and the frequency limitation has been exceeded. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.
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, oral surgery procedure and infiltration of sustained release therapeutic drug are not among those covered under this benefit. The contract says that restorations are limited to two procedures per calendar year. The record shows that you received two resin-based composites on October 19, 2020, and your restorations benefit has been exhausted. The Plan contract also clearly states that you are responsible for the difference between the billed amount and allowed amount for covered services that are received OON. The record shows that you did not contact the Plan prior to the dates of service to verify benefits and provider eligibility. Therefore, we decided that the Plan does not have to pay for the oral surgery procedure, three infiltrations of sustained release therapeutic drugs, comprehensive oral evaluation, and four resin-based composites provided from October 7, 2020, to November 11, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit, panoramic jaw x-ray, two extractions, first 15 minutes of intravenous moderate (conscious) sedation/analgesia, and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia provided from November 2, 2020, to November 24, 2020.

You asked the Plan to pay for the outpatient office visit, panoramic jaw x-ray, and intravenous moderate (conscious) sedation/analgesia services. You say that you believe these services should be covered because they were medically necessary. The Plan denied your request. The Plan says these services were not preventive dental services that are covered under your plan. The Plan also says that you did not purchase the additional optional supplemental dental benefit that covers restorative dental services.

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 outpatient office visit, panoramic jaw x-ray, two extractions, first 15 minutes of intravenous moderate (conscious) sedation/analgesia, and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia provided from November 2, 2020, to November 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Albuterol inhaler provided in an outpatient setting on March 16, 2020.

You asked the Plan to pay for the Albuterol inhaler. You say that you only went to the facility for pain or Covid-19 testing. You say that you feel you should not be liable for the claim. The Plan denied your request. The Plan says the Albuterol inhaler is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the Albuterol inhaler is not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Albuterol inhaler provided in an outpatient setting on March 16, 2020.

Benefits for the Albuterol inhaler may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on September 28, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you need help waiving this amount due to a hardship in finances. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency services in an emergency room. You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show you were treated in the ER. 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 ER visit provided on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on November 14, 2020.

You asked the Plan to pay for domiciliary, rest home visit. You say that The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 domiciliary, rest home visit. 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 a domiciliary, rest home visit provided on November 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom upper compression garment identified with code E1399 that were issued on October 26, 2020.
You asked the Plan to pay for the custom upper compression. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee did not meet criteria for the items rendered.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code E1399 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means that the enrollee does not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the custom upper compression garment identified with code E1399 that were issued on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for advance care planning (99497) provided on June 23, 2020.

You asked the Plan to pay for advance care planning. You say that this is documented in the records. The Plan denied your request. The Plan says the records are for an incorrect date of service.

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 code 99497 is not supported in the medical record. Specifically, the submitted medical records are for June 3, 2020, rather than the billed date of service June 23, 2020. With the records provided, the billed code cannot be verified for the billed date of service. Based on this information, we decided that Medicare rules for coverage of advance care planning have not been met. Therefore, we decided that the Plan does not have to pay for advance care planning (99497) provided on June 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140).

You asked the Plan to pay the in network rate for the limited oral evaluation. You say that you were unaware that the plan only provided benefits for services that you receive in network. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that the provider in this case is out of network. The Plan also says that your plan does not have out of network 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, limited oral evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay 50% of the billed amount for the oral exam (D0120), cleaning (D1110), and bitewing x-rays (D0274) provided on November 5, 2020.

You asked the Plan to pay 50% of the billed amount for the dental services. You say that the book of benefits said the insurance would pay 50% of the charges of an out of network dentist. You say that you did not get 50% of the charges. You say that the book does not say anything about charges set by the Plan. You say that you did not do a pre-call as these are ordinary procedures. You also say that you feel that you were misled. The Plan denied your request. The Plan says dental services are paid based on the in network fee schedule. The Plan also says that out of network providers can bill you for the difference between what the provider bills and the plan pays.

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 the services are listed as covered, dental services that you receive out of network are paid based on the in network fee schedule. Additionally, the Evidence of Coverage clearly states that benefits received out of network are subject to any in network benefit maximums, limitations, and/or exclusions. Therefore, we decided that the Plan does not have to pay 50% of the billed amount for the oral exam (D0120), cleaning (D1110), and bitewing x-rays (D0274) provided on November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Laminotomy.

You asked the Plan to pay for Laminotomy (63042). You say that you made three attempts to file this claim. The Plan denied your request. The Plan says the claim was untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for Laminotomy (63042) was not filed until November 12, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the Laminotomy.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the extraction (D7210) and intravenous moderate (conscious)
sedation/analgesia (D9239 and D9243). We decided that the Plan does not have to pay for the problem focused
limited oral evaluation (D0140) and therapeutic parenteral drug (D9610).

You asked the Plan to pay for the problem focused limited oral evaluation (D0140), extraction (D7210), first 15
minutes of intravenous moderate (conscious) sedation/analgesia (D9239), each subsequent 15-minute
increment of intravenous moderate (conscious) sedation/analgesia (D9243), and therapeutic parenteral drug
(D9610). You say that you were told that this provider accepted your insurance. The Plan says that these
services are not allowed because they were performed by a provider who has chosen to opt out of Medicare.

We decided that the Plan has to pay for the extraction (D7210) and intravenous moderate (conscious)
sedation/analgesia (D9239 and D9243).

The Plan follows Medicare rules. Medicare rules say that an MA organization may make payment to a
physician or practitioner described in paragraph (a) of this section for services that are not basic benefits but are
provided to a beneficiary as a supplemental benefit consistent with 42 CFR section 422.102.

The Plan says that you received these services from a Medicare opt out provider. The Plan verified with the
provider that there was not a private contract between you and the provider regarding your financial
responsibility for these services. There was no notice provided in the EOC that services with an opt out
provider would not be covered for supplemental dental benefits. Therefore, we decided that the Plan has to pay
for the extraction (D7210) and intravenous moderate (conscious) sedation/analgesia (D9239 and D9243).

We also decided that the Plan does not have to pay for the problem focused limited oral evaluation
(D0140) and therapeutic parenteral drug (D9610).

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
problem focused limited oral evaluation (D0140) and therapeutic parenteral drug (D9610).

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: Unfavorable

We decided that the Plan does not have to pre-approve two bone replacement grafts (D7953 x2), six simple extractions (D7140 x6), two surgical extractions (D7210 x2), first 15 minutes of deep sedation/general anesthesia (D9222), and three subsequent 15 minute increments of deep sedation/general anesthesia (D9223 x3).

You asked the Plan to pre-approve the bone replacement grafts, extractions, and deep sedation/general anesthesia services. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are excluded from coverage.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pre-approve 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 pre-approve two bone replacement grafts (D7953 x2), six simple extractions (D7140 x6), two surgical extractions (D7210 x2), first 15 minutes of deep sedation/general anesthesia (D9222), and three subsequent 15 minute increments of deep sedation/general anesthesia (D9223 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removal of an impacted tooth (D7240).
You asked the Plan to pre-approve the removal of an impacted tooth. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit 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 pre-approve a removal of an impacted tooth (D7240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two extractions (D7140 x2).

You asked the Plan to pre-approve the extractions. You say that you need to have these extractions so you can get an implant. 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two extractions (D7140 x2).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services provided on October 20, 2020.
You asked the Plan to pay for the surgical pathology services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 surgical pathology 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 surgical pathology services provided on
October 20, 2020.