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

We decided that the Plan does not have to pay for the hearing aids purchased on February 18, 2020 from an out-of-network provider.
You asked the Plan to pay for the hearing aids. You say that to deny you coverage is unacceptable. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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. Review of the file show that you purchased the hearing aids on February 18, 2020 from an out-of-network provider. Your EOC states, members are required to contact the Plan's hearing vendor to access the hearing aid evaluation and fitting benefits. 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. 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 hearing aids purchased on February 18, 2020 from an out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 25, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lower partial denture (D5214) and upper partial denture (D5213).
You asked the Plan to pre-approve the dental services. You say that your partial is old and a piece of it broke off and a tooth fell off that was on it. They no longer make this type of partial so you must have a whole new one. The Plan denied your request. The Plan says this service is not 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 pre-approve lower partial denture (D5214) and upper partial denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe oxygen concentrator rental provided on March 18, 2020.You asked the Plan to waive the coinsurance forthe oxygen concentrator rental. You say that you never used the oxygen concentrator.The Plan denied your request. The Plan says the oxygen concentrator was not returned therefore you were charged the coinsurance 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 20% coinsurance for durable medical equipment and related supplies. You have been asked to pay 20% coinsurance for the oxygen concentrator rental. the oxygen concentrator rental falls within the durable medical equipment and related 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 coinsurance forthe oxygen concentrator rental provided on March 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore buildup to tooth #18 (D2950).You asked the Plan to pre-approvecore buildup to tooth #18. You say that the service is necessary.The Plan denied your request. The Plan says the requested service is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers adental 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-approvecore buildup to tooth #18 (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 95861, CPT 95812) provided on August 5, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed services cannot be verified.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 95861 is "Needle electromyography; 2 extremities with or without related paraspinal areas". The CPT Code Manual definition of code 95812 is "Electroencephalogram (EEG) extended monitoring; 41-60 minutes".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 payfor the services. Our reviewer says that the use of CPT codes 95861 and 95812 is not supported by the records provided. Our physician reviewer found that the Technical Report submitted did not include documentation of the evaluation of extremity muscles innervated by three nerves with a minimum of five muscles studied per limb. Additionally, the Technical Report does not indicate that EEG extended monitoring with a minimum of 8 channels was performed.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 services have not been met.Therefore, we decided that the Plan does not have to pay forthe services (CPT 95861, CPT 95812) provided on August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on December 15, 2019 by
an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says prior authorization was obtained. The Plan
says that the referring facility is also out-of-network.
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 skilled nursing services provided on December 15,
2019 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 extraction provided on December 20, 2019.You asked the Plan to pay for the extraction. You say that this service should be covered as non-routine dental coverage because it was performed by a physician.The Plan denied your request. The Plan says the extraction does not fall into the category of Medicare-covered non-routine dental services.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 your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay for the extraction provided on December 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 19, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation
submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests
are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. 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 the drug testing services provided on November 19, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health skilled nursing services.
You asked the Plan to pre-approve additional services. You say that there have been recent exacerbation related
to the enrollee's diagnoses, medication, and homebound status. The Plan denied your request. The Plan says
there has been no recent changes to the enrollee's treatment plan or medications.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
The file shows that 9 home health nursing visits were requested. The Plan agreed to pre-approve 2 nursing
visits. 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 additional nursing visits. Our
physician reviewer found that the enrollee is noted to have pain, and skin/wound care needs, both involving the
bilateral lower extremities. The enrollee is non-toxic and afebrile. She is able to make her needs known. The
enrollee is documented as being home-confined. The treatments have included medications and in-home care.
The records do not show that skilled nursing services are required to effectively provide treatment, care, and/or
services in order to improve the enrollee's condition, or to establish/perform a maintenance program to
maintain the patient's condition and/or prevent deterioration. Additional skilled nursing is not needed above a
non-skilled individual to safely and adequately care for this enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional services have not been met. Therefore, we decided that the Plan does
not have to pre-approve additional home health skilled nursing services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network provider.You asked the Plan to pre-approvethe referral. You say that you have been trying to get treatment for over a year, and you have been toldthere is nothing that can be done.The Plan denied your request. The Plan says you are contractually required to obtain this service from network providers.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-approvea referral to an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction provided on January 28, 2020.
You asked the Plan to pay for the extraction. You say that you expected the dentist to be paid whether he is in-network
or out-of-network. You also say that you will not pay your monthly premium since the Plan did not
pay for your dental services. The Plan denied your request. The Plan says your 2020 Dental Plan does not show
that you have the optional benefit that covers comprehensive dental services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. The Plan confirmed that you are not enrolled in the optional dental
benefits. Therefore, we decided that the Plan does not have to pay for the extraction provided on January 28,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 molecular pathology genomic profiling
provided on January 31, 2020.
You asked the Plan to pay for the Guardant360 molecular pathology genomic profiling. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services
rendered were billed incorrectly.
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 the Guardant360 molecular pathology genomic profiling is not supported in the medical record.
Specifically, Medicare requires the use of CPT 81479 to report this testing. Also, the appropriate Dex Z-Code
identifier must be entered adjacent to the CPT code 81479 in the comment/narrative field. Based on this
information, we decided that Medicare rules for coverage of the Guardant360 molecular pathology genomic
profiling have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360
molecular pathology genomic profiling provided on January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on March 2, 2020 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you were unaware that the provider you were referred to was out-of-network.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 requestedprovider 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. 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 forphysician services provided on March 2, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial observation care (99220) provided February 10, 2020.
You asked the Plan to pay for initial observation care. You say that the claim was denied as a duplicate. The enrollee was seen by 2 different providers on 2 different days with 2 different specialties. The Plan denied your request. The Plan says that the initial observation care evaluation and management service was reported for the previous date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Documentation supports the rendering provider saw the enrollee on 2/10/20, however they are not the provider that admitted the patient into observation care. A more appropriate code would need to be billed to support the services rendered. Based on this information, we decided that Medicare rules for coverage for the initial observation care have not been met. Therefore, we decided that the Plan does not have to pay for initial observation care (99220) provided February 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided you do not require the services on an inpatient basis, in a skilled nursing facility setting. Services in a long-term care facility, assisted living facility or in the home with home health services on a part time basis appears appropriate in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310), pulp vitality tests (D0460), treatment of root canal obstruction (D3331), and retreatment of previous root canal therapy (D3348) provided on March 11, 2020 and March 18, 2020.You asked the Plan to pay for the consultation, pulp vitality tests, treatment of root canal obstruction, and retreatment of previous root canal therapy. You say that you are new to dental coverage and are surprised that your insurance did not cover this procedure.The Plan denied your request. The Plan says these services are not covered under your contract under any normal circumstances.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 consultation (D9310), pulp vitality tests (D0460), treatment of root canal obstruction (D3331), and retreatment of previous root canal therapy (D3348) provided on March 11, 2020 and March 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the IRF level care is medically necessary. The Plan
denied your request. The Plan says the enrollee's needs can be met in a lower level of care such as SNF or
outpatient therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found while the enrollee may benefit and participate in multiple therapies, her functional
level does not require this on an intensive rehabilitation therapy program provided in an IRF. Services can be
provided at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus gene panel provided on November 27, 2019 by
an out of network (OON) provider.
You asked the Plan to pay for the Tempus gene panel. 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 has network providers
available who can provide 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 Tempus gene panel provided on November 27,
2019 by an out of network (OON) provider.