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

We decided that the Plan does not have to pay the in network rate for the oral exam (D0120), the cleaning (D1110), the bitewing x-rays (D0274), the unspecified preventive service (D1999), and the sales tax (D9985) provided on December 10, 2020.
You asked the Plan to pay the in network rate for the dental services. You say that you have been seeing this dentist since 1996. You say that you moved your permanent residence to Florida in 2019. You say that you changed your plan accordingly. You say that the difference in coverage should have been better explained to you when you changed plans. You also say that the services should be covered as in network. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services that you receive out of network are paid based on the average negotiated in network fee schedule (INFS).
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 oral exam, cleaning and bitewing x-rays are listed as covered, dental services that you receive out of network may cost more. Additionally, the unspecified preventive service and sales tax are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the oral exam (D0120), the cleaning (D1110), the bitewing x-rays (D0274), the unspecified preventive service (D1999), and the sales tax (D9985) provided on December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the full amount for the filling (D2394) for tooth # 28, the filling (D2393) for tooth # 29, and the filling (D2392) for tooth # 31 provided on November 9, 2020.

You asked the Plan to reimburse the full amount for the dental services. You say that you were advised before your appointment that the services would be covered. You say that after you received the services you were told it was not covered and the money was due then. You say that you called the Plan when you got home and were advised again that the services were covered. The Plan denied your request. The Plan says there is a $1,000 annual maximum benefit. The Plan says that the annual maximum benefit has been exhausted while processing this claim. The Plan also says that payment cannot be issued for dental services above the maximum allowable of $1,000.

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 fillings are listed as covered services, the annual maximum benefit has been exceeded in processing this claim.

Date of Service
CPT Code
Plan Paid
Your Responsibility

3/30/2020
D0140
$38
$26.96
D0220
$13
$15.87
D7140
$65
$88.17

11/4/2020
D0150
$82
$0
D0274
$64
$0
D0330
$117
$0
D0220
$28
$0

11/9/2020
D2393
$275
$0
D2393
$275
$0
D2394
$43
$262
D2393
$0
$275
D2392
$0
$230

TOTAL:
$1,000
$898

The Evidence of Coverage clearly states that after the annual maximum is exhausted, any remaining charges are your responsibility. Additionally, the record shows that you the treatment plan presented to you from the provider does show that the amounts issued by the insurance are an estimate and you may be held liable for more than what was estimated for your costs. Therefore, we decided that the Plan does not have to reimburse the full amount for the filling (D2394) for tooth
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found at the time of admission, the member required skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of 4/14/2021 the member did not require any skilled nursing or rehab services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care as of 4/14/2021. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services by the member's primary care physician.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided on September 23, 2020 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 surgical extractions (D7210 x 3), the initial 15 minutes of deep sedation (D9222), and the additional 15 minutes of deep sedation (D9223 x 2) provided on September 26, 2020.
You asked the Plan to pay for the dental services. You say that you contacted the plan looking for a list of in network providers. You also say that you were led to believe that if the provider was in network, the services would be covered. The Plan denied your request. The Plan says surgical extractions are not listed as covered services. The Plan says that deep sedation is not listed as covered either. The Plan also says that a list of in network oral surgeons and a breakdown of the code-specific benefits were provided via email.
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 surgical extractions (D7210 x 3), the initial 15 minutes of deep sedation (D9222), and the additional 15 minutes of deep sedation (D9223 x 2) provided on September 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by an out-of-network provider on November 6, 2020, to November 9, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this should be covered 100%. You say that you received financial aid from the hospital. The Plan denied your request. The Plan says the correct copayment has 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 $289 copayment per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care/in-network. You have been asked to pay a $289 copayment per day for days 1-2 for an inpatient hospital stay. The total amount you are being asked to pay is $578 ($289 x 2 days = $578). An inpatient hospital stay falls within the inpatient hospital care/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 inpatient hospital stay provided by an out-of-network provider on November 6, 2020, to November 9, 2020.
We note your complaint about receiving financial aid from the hospital. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for morphometric analysis including Her2 testing (88323, 88361) provided on July 28, 2020.
You asked the Plan to pay for morphometric analysis including Her2 testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that there is no recommendation for Her2 testing on in situ breast lesions outside of a clinical trial. We looked at the file and Medicare rules. The record shows that the enrollee was diagnosed with a situ breast lesion and was not in a clinical trial. Based on this information, we decided that Medicare rules for coverage of morphometric analysis including Her2 testing have not been met. Therefore, we decided that the Plan does not have to pay for morphometric analysis including Her2 testing (88323, 88361) provided on July 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit (CPT code E0745) provided to the enrollee on November 9, 2020, by a non-participating provider.

You asked the Plan to pay for the DME. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the services are considered experimental and investigational.

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 pay for the DME. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested neuromuscular stimulator, electronic shock unit (CPT code E0745) with supplies is not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k) as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The requested items are not being furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member. The requested item exceeds the patient's medical need. The documentation does not reveal an objective detailed neuromuscular hands-on examination of the patient supporting a need for the requested device and supplies therefore this request is not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit (CPT code E0745) provided to the enrollee on November 9, 2020, by a non-participating provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the extremity study provided by an out-of-network provider on August 20, 2020.
You asked the Plan to pay for the extremity study. You say that authorization was requested but not obtained. The Plan denied your request. The Plan says prior authorization was required but 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 extremity study provided by an out-of-network provider on August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on July 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says these services were not emergent/urgent.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided on July 21, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper denture (D5110).
You asked the Plan to pre-approve the dental services. You say that you lost your upper teeth, and you need
them to eat. You cannot eat without them and can't wait 5 years to get them. The Plan denied your request. The
Plan says this request exceeds the benefit frequency limitation.
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. The health plan contract says
that this service is covered only once every five years. The records show this service was provided November
3, 2020. Therefore, the benefit has been exhausted and will not be available until November 2025.
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
complete upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dermatology service provided on March 2, 2020 by an out of network provider.
You asked the Plan to pay for the domiciliary or rest home visit (99336). You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the dermatology service provided on March 2, 2020 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular panel (81439, 81185, 81286, 81238, 81410, 81411).
You asked the Plan to pay for a hereditary cardiovascular panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular panel have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular panel (81439, 81185, 81286, 81238, 81410, 81411).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the biopsy provided on November 10, 2020.
You asked the Plan to waive the copayment for the biopsy. You say that you would not have needed the procedure if the results were read correctly. You say that you should get a refund. 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 $200 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. You have been asked to pay a $200 copayment for the biopsy. The biopsy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 the biopsy provided on November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the provision of test materials provided from August 22, 2019, through December 16, 2019.

You asked the Plan to waive the copayment for the provision of test materials. You say that you were informed this was coded incorrectly and the billing errors should be corrected. 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 $40 copayment for medical supplies from an in-network provider. You have been asked to pay a total of $200 for the provision of test materials.

Date of Service
Service
Standard Copayment
Member Liability

August 22, 2019
Test Materials
$40
$40

September 20, 2019
Test Materials
$40
$40

October 17, 2019
Test Materials
$40
$40

November 18, 2019
Test Materials
$40
$40

December 16, 2019
Test Materials
$40
$40

TOTAL:
$200

The provision of test materials falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 the provision of test materials provided from August 22, 2019, through December 16, 2019.
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 9, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you had an appointment for the exact same service on November 2, 2020 and did not have a copayment. You say you should not have a copayment for this visit. 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 $30 copayment if services are provided by an in-network specialist. You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 the specialist office visit provided on November 9, 2020.
Please note, our decision is only regarding the November 9, 2020 service. Please contact the Plan directly with questions about previous billing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve disposable gloves.
You asked the Plan to pre-approve disposable gloves. You say that using a disposable glove is the only way for you to eliminate. Therefore, it is medically necessary for you to be approved your request. The Plan denied your request. The Plan says disposable gloves are hygienic items that are non-reusable and therefore not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve disposable gloves.