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

We decided that the Plan does not have to pay for the emergency department visit for tooth abscess services provided on December 9, 2020.
You asked the Plan to pay for the emergency department visit for tooth abscess services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the emergency department visit for tooth abscess services provided on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), (64490, 64491, 64492). You say that you want the Plan to condone your medically reasonable and necessary blocks and RFA requests. The Plan denied your request. The Plan says diagnostic injections or medial branch blocks at the same level as the previously successful radio frequency ablation procedure is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), (64490, 64491, 64492). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found repeat diagnostic MBBs do not need to be repeated after successful radio frequency ablation. The request is not medically reasonable or 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 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), (64490, 64491, 64492) have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a fluoride treatment (D1206) provided May 5, 2021.

You asked the Plan to pay for the fluoride treatment. You say that the services were medically necessary. The Plan denied your request. The Plan says this 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 a fluoride treatment (D1206) provided May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive evaluation (D0150), the interim partial maxillary denture (D5820) and the interim partial mandibular denture (D5821) provided from January 18, 2021 to March 8, 2021.
You asked the Plan to pay for dental codes D0150, D5820 and D5821. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental code D0150 is covered once every 3 Plan years. The Plan previously paid for dental code D0150 on the visit you had on September 2, 2020, which is less than 3 years ago. Dental codes D5820 and D5821 are not covered dental services under the Plan's supplemental dental 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, dental codes D5820 and D5821 are not among those covered under this benefit. Furthermore, the Plan contract clearly says that dental code D0150 is covered once every 3 Plan years. The file shows that the Plan had previously paid for dental code D0150 from your visit you received on September 2 2020, which is less than 3 years ago. Therefore, we decided that the Plan does not have to pay for the comprehensive evaluation (D0150), the interim partial maxillary denture (D5820) and the interim partial mandibular denture (D5821) provided from January 18, 2021 to March 8, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the services provided on January 5, 2021. We decided that the Plan does not have to pay for services provided on January 4, 2021.
You asked the Plan to pay for the services provided on January 5, 2021. The Plan says that the records do not support the service provided.
We decided that the Plan has to pay for the services provided on January 5, 2021.
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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT 99291 is supported in the medical record. Specifically, the records show that critical care was provided on the date of service at issue for 31 minutes. Based on this information, we decided that Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pay for the services provided on January 5, 2021.
We also decided that the Plan does not have to pay for services provided on January 4, 2021.
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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT 99291 code is not supported in the medical record. Specifically, there are insufficient records to show that critical care services were provided on January 4, 2021. The file shows that the Plan requested additional medical records on multiple occasions, with no success. 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 services provided on January 4, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and intraoral - periapical, first film (D0220) provided May 18, 2021.
You asked the Plan to pay for the dental services. You say that you only get $25 per month pension from social security. If you pay the dentist for his services, next month you will not be able to purchase the bandages and medications that you need. The Plan denied your request. The Plan says these services are not listed as covered under the Plan 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 limited oral evaluation (D0140) and intraoral - periapical, first film (D0220) provided May 18, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided from
September 17, 2020, to February 25, 2021.
You asked the Plan to pay for the services provided. You say that you are requesting reimbursement. The Plan
denied your request. The Plan says the claim denied correctly.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the
outpatient mental health services provided from September 17, 2020, to February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided by an opt out of Medicare
provider.
You asked the Plan to pay for the dental services provided by an opt out of Medicare provider. You say that
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the
dentist who provided the services in dispute has opted out of the Medicare program.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental services provided by an opt out of Medicare provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport and ground mileage (A0428, A0425) provided March 3, 2021.

You asked the Plan to pay for the non-emergency ambulance transport. You say that the services should be covered. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office or facility for a scheduled appointment is not a Medicare covered benefit.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the non-emergency ambulance transport. Our reviewer says that the non-emergency ambulance transport was not medically necessary. Our physician reviewer found that there was no evidence from the documentation that other means of transport, namely stretcher van or wheelchair van, would be contraindicated or not appropriate in this situation. The documentation does not support the enrollee needing expertise or special equipment for this non-emergent transport to a scheduled office visit. Vitals were stable and the enrollee did not require any treatment during transport. The documentation does not support that the ambulance services from March 3, 2021, were 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 the non-emergency ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport and ground mileage (A0428, A0425) provided March 3, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. You say that you would like to continue your care with this provider. The Plan denied your request. The Plan says there are contracted providers who can provide the requested services.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve outpatient mental health services to be provided by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for determination of refractive state (CPT code 92015) provided on April 27, 2021.
You asked the Plan to pay for the eye exam. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you exhausted your benefit.
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. We looked at the file and the Plan's rules. Review of the file shows that you had a routine eye exam on February 16, 2021. You also had another eye exam on April 27, 2021; however, your Plan only covers one (1) routine eye exam every calendar year. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay for determination of refractive state (CPT code 92015) provided on April 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code(s): 81291, 81479, 81439, 81407, 81408) provided to the enrollee on September 28, 2020.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.
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. Review of the file shows the enrollee had cardiovascular risk assessment testing on September 28, 2020. The denial remains upheld as non-covered as Medicare denies coverage for all cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code(s): 81291, 81479, 81439, 81407, 81408) provided to the enrollee on September 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for mammography services (77065) provided to the enrollee on March 9, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the claim was billed for two units, and per CMS.gov Medically Unlikely Edits Practitioner Services MUE Value the maximum frequency per day is one unit.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 77065 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for mammography services (77065) provided to the enrollee on March 9, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on May 8, 2021.
You asked the Plan to waive the copayment for the lab services. You say that your doctor requested that you redo your lab tests, so you do not believe you should have to pay a second copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $10 copayment for lab services. You have been asked to pay a $10 copayment for the lab services. This copayment applies regardless of the reason for the lab services. 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 lab services you received on May 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fixed partial denture sectioning (D9120).
You asked the Plan to pre-approve the dental service. You say that you would like to know what your options are if this service does not get approved. You also say that you have an infection. The Plan denied your request. The Plan says that fixed partial denture sectioning is not listed as a covered service.
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 fixed partial denture sectioning is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve fixed partial denture sectioning (D9120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99497, 99223) provided December 15, 2020.
You asked the Plan to pay for the hospital care. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 99497 & 99223 are not supported in the medical record. Specifically, the records
provided are for date of service December 16, 2020. No records were submitted for the correct date of service.
Based on this information, we decided that Medicare rules for coverage of the hospital care have not been met.
Therefore, we decided that the Plan does not have to pay for hospital care (99497, 99223) provided December
15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture with flexible base (D5226).

You asked the Plan to pre-approve the dental service. You say that your teeth have moved. You say that you need the flexible base. You also say that your dentist is not able to make your current denture work for you. The Plan denied your request. The Plan says partial lower denture with flexible base is not listed as a covered service.

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 partial lower denture with flexible base is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture with flexible base (D5226).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular risk analysis testing provided on March 9, 2021.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment tests/panels for suspected or documented cardiovascular disease.
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, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular risk analysis testing provided on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery and coinsurance for an injection provided by a participating provider on October 27, 2020, to November 24, 2020.

You asked the Plan to waive the copayment for an outpatient surgery and coinsurance for an injection. You say that these charges are unfair. The Plan denied your request. The Plan says the correct charges 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 20% coinsurance for Medicare Part B prescription drugs/in-network and a $325 copayment for outpatient surgery/in-network. 

You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount for the injections is $27,134.60. The amount you are being asked to pay for the injections is $5,426.92 ($27,134.60 x 20% = $5,426.92). You have been asked to pay $56.18 for each outpatient surgery which is less than your copayment amount of $325 for an outpatient surgery. The total amount you are being asked to pay is $5,539.28 ($5,426.92 + $56.18 + $56.18 = $5,539.28). An outpatient surgery falls within the outpatient surgery/in-network benefit category. An injection falls within the Medicare Part B prescription drugs/in-network 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 an outpatient surgery and coinsurance for an injection provided by a participating provider on October 27, 2020, to November 24, 2020.