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

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140)
received December 17, 2020.
You asked the Plan to pay for the limited oral evaluation. You say that you were referred to this provider by
another dentist. The Plan denied your request. The Plan says you exceeded the allowable frequency for this
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 service exceeds that
which is covered under this benefit. The Plan has submitted evidence that you received this same service on
December 2, 2020, exceeding the limit of one per year. Therefore, we decided that the Plan does not have to
pay for the limited oral evaluation - problem focused (D0140) received December 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 4, 2020.
You asked the Plan to pay for the laboratory 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.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultralight wheelchair with accessories provided on December 31, 2019, by an OON provider.

You asked the Plan to pay for an ultralight wheelchair with accessories. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

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 an ultralight wheelchair with accessories provided on December 31, 2019, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on
November 24, 2020.
You asked the Plan to waive the copayment for the laboratory services. You say that you would like the Plan to
reconsider your request. The Plan denied your request. The Plan says you received laboratory services on the
date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract
with the Plan.
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 Outpatient diagnostic tests.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received laboratory
services on November 24, 2020. You have been asked to pay a $10 copayment for the laboratory services. The
laboratory services fall within the Outpatient diagnostic tests 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 laboratory services provided on November 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided August 27, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the documentation is missing required information.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file shows that the proof of delivery did not include an itemize order form or invoice to indicate the specific supplies; therefore, the billed supply code cannot be verified. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided August 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites for the mesial, occlusal, distal, and lingual surfaces of tooth #'s 12 and 13 provided on November 25, 2020.

You asked the Plan to pay for the resin-based composites. You say that you would like to know if this service can be covered. The Plan denied your request. The Plan says these services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Tooth #'s 12 and 13 are posterior teeth, and the surfaces that were serviced were the mesial, occlusal, distal, and lingual surfaces. This Plan only covers resin-based composites on buccal surfaces of posterior teeth. Therefore, we decided that the Plan does not have to pay for the resin-based composites for the mesial, occlusal, distal, and lingual surfaces of tooth #'s 12 and 13 provided on November 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant 360 molecular pathology testing provided on September 18, 2020.
You asked the Plan to pay for the Guardant 360 molecular pathology testing. 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 as billed.
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, Medicare guidelines say when billing for the Guardant360 molecular lab panel, procedure code 81479 is the only code available for billing. Therefore, we decided that the Plan does not have to pay for the Guardant 360 molecular pathology testing provided on September 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on June 15, 2020.
You asked the Plan to pay for a lumbar-sacral orthosis. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the document provided as proof of delivery does not indicate that it pertains to the item at issue. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on June 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0676) provided on September 21, 2020.
You asked the Plan to pay for an intermittent limb compression device. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices are covered by Medicare only for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers. The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device (E0676) provided on September 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on October 15, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that you used the same provider in the past and were not charged a copayment. You state that you would like the services to be processed as in-network. 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 $10 copayment for out-of-network lab services provided at a laboratory facility. You received laboratory services from an out-of-network provider on October 15, 2020. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for out-of-network laboratory services. Laboratory services fall 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 laboratory services provided on October 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthotics provided on September 9, 2020.

You asked the Plan to pay for knee orthotics. You say that the doctor's progress not clearly documents the medical necessity for these items. The Plan denied your request. The Plan says the denial of payment for these items is correct, because there is no history from the prescribing provider on this date of service or within the 6 months prior to the date of service.

The Plan must follow Medicare rules. Medicare rules say that a face-to-face encounter must be performed within the 6 months prior to prescribing required DMEPOS items. 

We looked at the file and Medicare rules. The documentation submitted does not support that a face-to-face evaluation was performed within the 6 months prior to these items being ordered, or that the evaluation performed was by an approved use of telehealth examination. Based on this information, we decided that Medicare rules for coverage of knee orthotics have not been met. Therefore, we decided that the Plan does not have to pay for knee orthotics provided on September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal care services coded T1019 provided from May 19, 2020 to May 27, 2020.

You asked the Plan to pay for the personal care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 code T1019 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the personal care services have not been met. Therefore, we decided that the Plan does not have to pay for the personal care services coded T1019 provided from May 19, 2020 to May 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 16, 2020.
You asked the Plan to pay for the laboratory 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting.
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 16, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient mental health care provided from July 9, 2020 to September 15, 2020.

You asked the Plan to waive the copayments for the outpatient mental health care. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient mental health care on the dates of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.

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 Outpatient mental health care. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient mental health care from January 9, 2020 to November 19, 2020. The Plan overturned and paid for the outpatient mental health care, waiving your copayments for the July 28, 2020, August 4, 2020, September 24, 2020, October 1, 2020, October 13, 2020, October 22, 2020, November 17, 2020, and the November 19, 2020 dates of service. You have been asked to pay a $40 copayment for each outpatient mental health care visit on July 9, 2020, July 16, 2020, August 11, 2020, August 18, 2020, August 25, 2020, September 1, 2020, September 8, 2020, and September 15, 2020. The outpatient mental health care visits fall within the Outpatient mental health care benefit category.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammography services provided on October 1, 2020.

You asked the Plan to pay for the screening mammography services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says you are covered for these services once every 12 months. The Plan says that you had these services performed twice in 12 months and the claim denied due to maximum benefit has been exhausted.

The Plan must follow Medicare rules. The rules say that a Medicare Health Plan must disclose to its members the benefits offered under the plan including applicable conditions and limitations.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received these services in February of 2020. The Plan paid for these services with $0 as your responsibility. You then received the same services on October 1, 2020. Your Plan only covers these services once every 12 months. Therefore, we decided that the Plan does not have to pay for the screening mammography services provided on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the services provided by a specialist on
November 25, 2020.
You asked the Plan to waive the cost share for the services provided by a specialist. You say that you feel you
should not be responsible for this cost share amount and you would like the Plan to reconsider your request.
The Plan denied your request. The Plan says you received these services provided by a specialist on the date of
service at issue in this appeal. The Plan says that the correct cost share has applied per your contract with the
Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is $185 deductible that must be met before the Plan will pay their share
for Physician/Practitioner services. Your contract with the Plan also says that there is a 4% coinsurance for
services obtained by a specialist.
The item or service you asked the Plan to waive the cost share for falls within the benefit category
Physician/Practitioner services. The Plan has followed Medicare rules by clearly disclosing in the contract that
there is $185 deductible that must be met before the Plan will pay their share for Physician/Practitioner
services. This cost sharing is a contractual obligation that had not been met at the time the services provided by
a specialist was received on November 25, 2020. As your deductible was met during this date of service, your
coinsurance for specialist services also applies. You have been asked to pay a 4% coinsurance of the allowable
amount for procedure codes 17004 and 11102. Therefore, we decided that the Plan does not have to waive the
cost share for the services provided by a specialist on November 25, 2020.
Appeal type: Lab
Decision: Unfavorable

2020.
You asked the Plan to pre-approve the ConfirmMDx testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee did not meet criteria for the requested services.
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx testing is only covered when the enrollee has received a previous biopsy.
Review of the file shows that the Plan uses LCD L37005 to support their denial. However, LCD L37005 is not valid for the provider's state of California. Therefore, we are unable to use LCD L37005 to substantiate our decision. We looked at the file and Medicare rules. The documentation does not support that the enrollee has had a previous cancer-negative prostate biopsy. Based on this information, we decided that Medicare rules for coverage of the ConfirmMDx testing have not been met. Therefore, we decided that the Plan does not have to pre-approve the ConfirmMDx testing provided on November 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274), the unspecified preventive service (D1999), and the unspecified fixed prosthetic service (D6999) provided on January 28, 2021.
You asked the Plan to pay for the dental services provided on January 28, 2020. You say that you received a letter advising that you owe money for dental services that you received on January 20, 2021, and January 28, 2021. You say that you cannot afford to pay this. You also say that you do not want to have to go back to the dentist again in 3 years. The Plan denied your request. The Plan says bitewing x-rays are covered once per year. The Plan says that the frequency limit for this service has been exceeded. The Plan also says that unspecified preventive service and unspecified fixed prosthodontic service are not listed as covered 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 bitewing x-ray is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for bitewing x-rays that you received on January 20, 2021. Additionally, unspecified preventive service and unspecified fixed prosthodontic service are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274), the unspecified preventive service (D1999), and the unspecified fixed prosthetic service (D6999) provided on January 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional HHA services.
You asked the Plan to pre-approve the additional HHA services. You say that you need more hours with a home health aide. The Plan denied your request. The Plan says the documentation sent indicates that you refuse personal care, you receive some ambulation activity and maintenance exercises but most of what is being provided is incidental services such as meals, empty trash, tidy the bedroom and kitchen, make the bed, etc. The Plan also says that the documentation does not support the request for additional home health aide services.
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. 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 additional HHA services. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the documentation does not support that you require skilled nursing services or skilled rehab services to provide treatment that is medically necessary. Our reviewer found that you do not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration.
Our physician reviewer also found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 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 additional HHA services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional HHA services.