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

We decided that the Plan does not have to pay for the reline of a complete mandibular denture (D5751) and
reline of a maxillary partial denture (D5760) provided on October 26, 2020.
You asked the Plan to pay for the denture relines. You say that the Plan says that the treating provider is not innetwork.
You also say that you confirmed with your agent that the treating provider is in-network. The Plan
denied your request. The Plan says these services 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. Therefore, we decided that the Plan does not have to pay for the reline
of a complete mandibular denture (D5751) and reline of a maxillary partial denture (D5760) provided on
October 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment without transportation (A0998) provided on February 26, 2021.

You asked the Plan to pay for the ambulance response and treatment without transport. You say that these services were necessary, but you preferred to have your spouse drive you to the ER when the treatment at the scene was insufficient. You did not realize these services would not be covered and feel this cost is a burden. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. If you are not transported in the ambulance, there is no payable service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 26, 2021. 

The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without transportation (A0998) provided on February 26, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes (12011) provided August 22, 2020.
You asked the Plan to pay for the wound repair. You say that you request that the surgical code be considered for separate reimbursement and not bundled under the payment for the evaluation and management CPT code. The Plan denied your request. The Plan says unbundled service. The claim was processed and paid under the primary procedure.
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, we have confirmed that code the wound repair has a bundled relationship with code 21310 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes (12011) provided August 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that this is needed to treat leg pain. The Plan denied your request. The Plan says this is not covered by Medicare or the plan.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are non-covered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy with an out-of-network provider.

You asked the Plan to pre-approve out-of-network physical therapy. You say that you need physical therapy and your doctor ordered it. The Plan denied your request. The Plan says in-network providers are 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 physical therapy with an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on May 1, 2020.
You asked the Plan to pay for this service. . You say that this service should be covered by the Plan. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on May 1, 2020 and received by the lab on May 4, 2020.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due to an error with the POS codes reported. Medicare rules for coverage of this service are not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on May 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for laboratory services provided to the enrollee on February 5, 2021.

You asked the Plan to pay for this claim as billed. You say that this service should be covered by the Plan. 
The Plan denied your request. The Plan says the claim form indicates the laboratory specimen was obtained in a 
laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that 
the specimen was obtained in an office setting POS 11; therefore, the billed code cannot be verified. It 
is noted multiple attempts were made to obtain additional information from the provider.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case this claim cannot be paid as billed due to an issue the Place of Service (POS) codes billed. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on April 19, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that the provider provides acute visits to the enrollee at the nursing home. You say under traditional Medicare, this claim would not need authorization. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on April 19, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 10, 2021.
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 this type of test is not covered for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the custom fabricated abutment (D6057).
You asked the Plan to pre-approve the custom fabricated abutment. You say that you need the crown and abutment for your dental implant. The Plan denied your request. The Plan says this service 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, 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 the custom fabricated abutment (D6057).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.
You asked the Plan to pre-approve Dupixent. The Plan denied your request. The Plan says this drug is not covered under 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 pre-approve Dupixent.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing provided on February
24, 2021.
You asked the Plan to pay for periodontal scaling and root planing. You say that you followed guidelines by
calling the appeal and mailed in the appeal concerning dental coverage. The Plan denied your request. The Plan
says the 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 pay for
periodontal scaling and root planing provided on February 24, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management provided on December 11, 2020.
You asked the Plan to pay for the hospital discharge day management. You say that this was the only service billed on this date and it is an appropriate hospital discharge code. You say that the physician is a hospitalist and should be reimbursed for the discharge. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management provided on December 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is unable to be placed in a lower level of care. The Plan denied your request. The Plan says that the documentation fails to indicate that the member requires acute services that are available only in an LTACH.
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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 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 for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided on April 9, 2021 by an
OON provider.
You asked the Plan to pay for the home health services. You say that this enrollee needed to be seen for his
diabetes and hypertension. You also say that you would like the provider to be reimbursed for the services that
were rendered. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the home health services provided on April 9,
2021 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxybutynin tablet 5mg ER for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says non-injectable, self-administered drugs are not covered.
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 pre-approve Oxybutynin tablet 5mg ER for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty (D4212), preventive procedure (D1999), and complete series of intraoral x-rays (D0210) provided on February 9, 2021, and February 18, 2021.
You asked the Plan to pay for the gingivectomy or gingivoplasty, preventive procedure and complete series of intraoral x-rays. You say that the gingivectomy or gingivoplasty was required to cut away the gum to fill the tooth. You also say that the preventive procedure is required by a government mandate for the Coronavirus. The Plan denied your request. The Plan says these 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 pay for the gingivectomy or gingivoplasty (D4212), preventive procedure (D1999), and complete series of intraoral x-rays (D0210) provided on February 9, 2021, and February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2790).
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says this service is 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. Therefore, we decided that the Plan does not have to pre-approve a crown (D2790).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the bitewing x-ray
(D0270) provided on April 6, 2021.
You asked the Plan to pay for the dental services. You say that you had a filling fall out in January. You say
that you felt you needed to wait until you received both coronavirus vaccinations before you went back to the
dentist. You say that you were advised you needed to have an exam because so much time had elapsed. You
also say that you do not feel that it was unreasonable to have delayed treatment. The Plan denied your request.
The Plan says 1 limited oral evaluation is covered every plan year. The Plan says that bitewings are covered
once every plan year. The Plan also says that the frequency limits have 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 the services are listed as covered,
the frequency limits have been exceeded. The record shows that the Plan paid for a limited oral evaluation and
bitewing x-ray that you received on January 11, 2021. Therefore, we decided that the Plan does not have to pay
for the limited oral evaluation (D0140) and the bitewing x-ray (D0270) provided on April 6, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided to the enrollee on October 20, 2020.
You asked the Plan to pay for this testing. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says that this is an administrative denial based on a coding issue. The Plan states that based on the Medicare guidelines, this claim should be billed as Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel by MolDX; and it is a test not currently satisfactorily described by any existing procedure code. The Plan says to report this testing service providers should use procedure code 81479 (used for the entire bundled multi-test panel) in addition to the approved DEX Z-Code TM entered adjacent in the comment/narrative field for the test and not bill unbundled to separate codes. The Plan is applying this guidance using Medicare Local Coverage Article: Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Sequencing Testing in [Solid Tumor] Cancers (A55624), Medicare Local Coverage Article (A57936): Billing and Coding: MolDX: Plasma-Based Genomic Profiling [Solid Tumors] , and Medicare Local Coverage Article: Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Next Generation Sequencing Testing in Cancer (A55197).
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plans are expected to use Medicare regulations that have a MAC B jurisdiction designation for either the state the enrollee lives in or the state in which the provider is located. The regulations referenced by the Plan do not show MAC B jurisdiction for the state the enrollee lives in or in the state the provider is located in and therefore do not apply. This means, the Plan has not substantiated its denial as the appropriate Medicare regulations were not used to determined coverage or coding guidelines. Therefore, we decided that the Plan has to pay for genetic testing provided to the enrollee on October 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (codes 80053, 81001, 83036, 83690, 85025, and 87086) provided to the enrollee on October 8, 2020.
You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says screening tests in the absence of illness or disease are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The services at issue were requested solely for screening purposes. Medicare does not cover this service solely for screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory services (codes 80053, 81001, 83036, 83690, 85025, and 87086) provided to the enrollee on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on November 24, 2020.

You asked the Plan to waive the copayment for the specialist office visit. You say that you saw the provider but did not get services since they were concerned you had the coronavirus and were asked to reschedule your appointment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each covered specialist office visit.

You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you were assessed for sarcoidosis and your treatment plan is to complete a pulmonary function test.

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 specialist office visit provided on November 24, 2020.