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

We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and implant supported crowns (D6066) for teeth # 19 and 20.

You asked the Plan to pre-approve the dental services. You say that these services are necessary in order to complete the procedure. You say that the enrollee already had implants surgically placed last year. You also say that the services are medically necessary. The Plan denied your request. The Plan says custom fabricated abutments are not listed as covered services. The Plan says that implant supported crowns are not listed as covered services. The Plan also says that any services not listed 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. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and implant supported crowns (D6066) for teeth # 19 and 20.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the self-administered drugs provided in an outpatient setting from October 7, 2020, to October 9, 2020.

You asked the Plan to reimburse you for the self-administered drugs. You say that you paid out of pocket for these charges. You also say that you should be reimbursed. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are 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 reimburse you for the self-administered drugs provided in an outpatient setting from October 7, 2020, to October 9, 2020.

Benefits for the self-administered drugs 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing provided on November 16, 2020.

You asked the Plan to pay for Guardant360 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 the enrollee previously received covered Guardant360 testing for the same cancer diagnosis on August 19, 2020.

The Plan must follow Medicare rules. Medicare rules say that Guardant360 is only covered under certain conditions, including that the enrollee has not previously been testing with the Guardant360 test for the same primary cancer. We looked at the file and Medicare rules. The enrollee was previously testing with Guardant360 for the same primary cancer on August 19, 2020. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing provided on November 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on December 2, 2020.

You asked the Plan to waive the copayment for a CT scan. You say that you have never been charged in the past because the service is a screening. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $150 copayment for diagnostic radiology services. 

You have been asked to pay a $150 copayment for a CT scan. A CT scan 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 a CT scan provided on December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for mechanical traction (97012) provided July 30, 2020.

You asked the Plan to pay for the chiropractic services. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. 

The Plan says office visits for evaluation and management, physical therapy modalities, x-rays and diagnostic testing, rehabilitation and other incidental services by chiropractors are not covered by Medicare.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for mechanical traction (97012) provided July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on October 4, 2020.

You asked the Plan to waive the copayment for urgently needed services. You say that you only paid a $10 copayment for urgently needed services in the past and disagree with the increase in charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $60 copayment for urgently needed services. 

You have been asked to pay a $60 copayment for urgently needed services. Urgently needed services fall within the urgently needed services 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 urgently needed services provided on October 4, 2020.

We note your complaint that the copayment increased and you were not informed of the higher charges. 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 lab services (81479) provided on November 4, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not pre-authorized by the plan.

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 services 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 these services. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided on November 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodic oral evaluation (D0120), the bitewing x-rays (D0274), the periodontal maintenance (D4910), the core build up (D2950) provided from October 8, 2020, to November 2, 2020.
You asked the Plan to reimburse you for the dental services. You say that you were told that you were told any doctor had to accept Medicare patients. You say that you called the provider's office and were advised they do accept Medicare patients. You say that you did not have a 2020 Evidence of Coverage. You also say that you did not know what it meant to "opt out of Medicare." The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot be made for dental services that you receive from a provider who has opted out of Medicare.
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, payment cannot be made for dental services that you receive from a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to reimburse you for the periodic oral evaluation (D0120), the bitewing x-rays (D0274), the periodontal maintenance (D4910), the core build up (D2950) provided from October 8, 2020, to November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain fused to high noble metal (D2750) and a root canal (D3310).

You asked the Plan to pre-approve the dental services. You say that the crown was denied initially because the wrong code was submitted. You say that you asked for the correct code to see if you could get it approved. You also say that the root canal should be covered too. The Plan denied your request. The Plan says referrals are required from your general dentist for services provided by a specialist. The Plan also says that there is no referral for the requested 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 and the services are listed as covered, a referral is required from your general dentist. The Evidence of Coverage clearly states that referrals to specialists including, endodontists, oral surgeon, periodontist, and prosthodontist are required from your general dentist. Therefore, we decided that the Plan does not have to pre-approve a porcelain fused to high noble metal (D2750) and a root canal (D3310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740).

You asked the Plan to pre-approve the crown. You say that this service is medically necessary for the enrollee. 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 crown (D2740).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0429) provided on July 21, 2020.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not billed according to CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code A0429 is not supported in the record. Specifically, when a beneficiary is pronounced dead after the ambulance is called but before the ambulance arrives, providers must report CPT code A0428 with the QL modifier. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0429) provided on July 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 18, 2020, by
an OON provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 the laboratory services provided on December 18,
2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator (E1390) and portable oxygen (E0431) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve an oxygen concentrator and portable oxygen. You say that these items are medically necessary. The Plan denied your request. The Plan says there are providers in-network available to provide the medical care you need.

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 an oxygen concentrator (E1390) and portable oxygen (E0431) to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22870, 22869).

You asked the Plan to pre-approve the interspinous spacer placement. You say that the services are medically necessary. The Plan denied your request. The Plan says this procedure is investigational and is not covered.

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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex spacer device is experimental. More research is needed to show safety and efficacy of the device. 

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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22870, 22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visit, x-rays and betamethasone acetate injection provided on October 12, 2020.
You asked the Plan to waive the cost share for the office visit, x-rays and betamethasone acetate injection. You say that you have never had to pay a copayment for ultrasounds before. You say that you do not believe you need to pay this. The Plan denied your request. The Plan says the cost share 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 $35 copayment per visit to a specialist, a $20 copayment for most x-rays and ultrasounds and 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a total of $77.62 for the office visit, x-rays and betamethasone acetate injection.
Service
Allowed Amount
Standard Cost
Member Liability
Office Visit
$106.55
$35
$35
X-Ray
$34.14
$20
$20
X-Ray
$34.14
$20
$20
Betamethasone Acetate Injection
$13.10
20%
$2.62
TOTAL:
$77.62
The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The x-rays fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The betamethasone acetate injection falls within the "Medicare Part B prescription drugs" 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 cost share for the office visit, x-rays and betamethasone acetate injection provided on October 12, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency care rendered.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that no Medicare payment is provided for VA services.

We looked at the file and Medicare rules. The services at issue were rendered at a VA hospital. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency care rendered.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vagus nerve stimulator (VNS).

You asked the Plan to pre-approve Vagus nerve stimulator. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that VNS is only covered for certain indications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Vagus nerve stimulator. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee has a history of medically refractory epilepsy. The documentation does
not support etiology of the enrollee's seizures (more specifically it is unclear if they are partial onset).
Furthermore, there were no neurology records provided showing that the enrollee's condition is not one for
which surgery could be performed. Therefore, the enrollee does not meet criteria for the requested 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 Vagus nerve stimulator have not been met. Therefore, we decided that the Plan
does not have to pre-approve Vagus nerve stimulator (VNS).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on October 28, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you paid a $45 copayment and received a bill for additional charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $45 copayment for each specialist visit. You have been asked to pay $26, which is less than the $45 copayment for a specialist visit. A specialist 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 a specialist visit provided on October 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance services and a SNF stay
provided from August 25, 2020, to October 8, 2020.
You asked the Plan to waive the copayments for ambulance services and a SNF stay. You say that you broke
your knee due to negligence and disagree with the charges. The Plan denied your request. The Plan says the
claims were processed correctly, and you are being charged the correct 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 $275
copayment for ambulance services. Your contract with the Plan also clearly says that you must pay a $0
copayment for days 1-20, and a $178 copayment for days 21-100, for SNF care.
You received ambulance services on August 25, 2020. Therefore, you are responsible to pay the allowed
amount of $235.46, which is less than the $275 copayment.
You received a SNF stay from September 24, 2020, to October 8, 2020. The record shows that you had a
previous SNF stay within the same benefit period for a total of 17 days. Therefore, you are not being charged
for days 18-20 (September 24, 2020, to September 26, 2020). You are responsible to pay a $275 copayment for
days 21-31 (September 27, 2020, to October 7, 2020). $178 (copayment) x 11 (SNF days) = $1,958.
The total amount you owe is: $2,193.46.
You have been asked to pay the total copayment amount of $2,193.46 for ambulance services and a SNF stay.
Ambulance services fall within the ambulance services benefit category. A SNF stay falls within the SNF care
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 copayments for ambulance services and a SNF
stay provided from August 25, 2020, to October 8, 2020.