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

We decided that the Plan does not have to pay for gingivectomy or gingivoplasty (D4211), an extraction
(D7210), and a bone replacement graft (D4263) provided on December 29, 2020.

You asked the Plan to pay for gingivectomy or gingivoplasty, an extraction, and a bone replacement graft. You
say that you want the Plan to pay for these services. The Plan denied your request. The Plan says The Plan says
you are not covered for services when seen by an out-of-network provider.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of gingivectomy or gingivoplasty, an extraction, and a bone replacement graft have not been met.
Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has
contracted providers available to provide these 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 gingivectomy or
gingivoplasty (D4211), an extraction (D7210), and a bone replacement graft (D4263) provided on December
29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiomyopathy testing services provided on September
4, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says Medicare
denies coverage for all cardiovascular risk assessment testing, except the basic lipid panel.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.

We looked at the file and the rules. The documentation does not show that the testing was ordered for a specific
diagnosis or treatment strategy. The testing was requested for screening purposes. Medicare does not cover this
testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the
cardiomyopathy testing services provided on September 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for OTC supplies provided on July 23, 2020.
You asked the Plan to pay for the OTC supplies. You say that these OTC items were necessary because the
enrollee had a tracheostomy and G-tube and needed a sterile environment. You say that the gloves received in
the trach care kits are not a sufficient quantity for the many things that are needed to be done, including trach
collar cleaning, adjustment and replacement, removal and replacement of the inner cannula, and frequent
suctioning. The Plan denied your request. The Plan says the items in dispute are not covered by Medicare or by
the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. The rules say
that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who
meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension.
Medicare rules state that incontinence supplies are not covered because they are hygienic items that are nonreusable.
The records show that you requested coverage of a blood pressure monitor. There is no evidence that this
monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected
white coat hypertension. The records show that you requested coverage of adult diapers. While incontinence
supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. You also
asked the Plan to pay for bed pads, 4x4s, alcohol wipes, dressings, paper tape, a pulse oximeter, Tylenol, Advil,
pillows, cotton swabs, stool softener, dry mouth wash, Benefiber, MiraLAX, Benadryl, gloves, Melatonin, and
antibiotic tape. These items are OTC items, which are not paid for by Medicare. Therefore, we decided that the
Plan does not have to pay for OTC supplies, the blood pressure cuff, or the incontinence supplies provided on
July 23, 2020.
We also see that in your appeal request you mention reimbursement for a nebulizer. However, review of the
receipts does not show whether you purchased this and, as such, we cannot determine whether reimbursement
is due. You may send evidence of this purchase to the plan and request reimbursement.
Appeal type: Transportation
Decision: Unfavorable

We decided the Plan does not have to pay for air ambulance transport provided to the enrollee on August 9, 2020.
You asked the Plan to pay for this transport. You say that you agree that the enrollee did not meet the criteria for air ambulance and submitted the claim with the GZ modifier requesting at least payment of ground mileage. The Plan denied your request. The Plan says Medicare coverage criteria for air ambulance were not met. Maximus overturned the Plans denial. The Plan requested a reopen that stated Maximus did not apply the correct criteria.
The Plan is correct in this case. The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. The trip report and the medical records clearly state by the provider that air transport was not medically necessary and that a modifier was attached to the claim in hope of at least being reimbursed for the equivalent of a ground transport. Medicare criteria for air transport were not met in this case. Therefore, we decided that the Plan does not have to pay for air ambulance transport provided to the enrollee on August 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the extracorporeal shock wave therapy (0101T) provided on September 25, 2020 to December 28, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the shock wave therapy. You say that you were charged and paid out of pocket in the amount of $3,995.00. You were not aware that a prior authorization was needed. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 extracorporeal shock wave therapy (0101T) provided on September 25, 2020 to December 28, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and lesion removal provided by an out-of-network provider on November 18, 2020.
You asked the Plan to pay for the office visit and lesion removal. You say that the patient came in and presented with Medicare, but Medicare denied stating the patient has other insurance. You say that payment should be considered on this claim. 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 office visit and lesion removal provided by an out-of-network provider on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the co-payment for the hospital outpatient clinic visit and chest x-rays provided on December 3, 2020.

You asked the Plan to reduce the co-payment for the hospital outpatient clinic visit for assessment and management of a patient (G0463) and Radiologic examination, chest; 2 views (71046). You say that you should only have a $20 co-payment. The Plan denied your request. The Plan says you were charged the co-payment correctly

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 co-payment for Outpatient diagnostic tests.

You have been asked to pay a $50 co-payment for the hospital outpatient Radiologic examination, chest; 2 views (71046). The hospital outpatient radiologic examination, chest; 2 views (71046) falls within the Outpatient Diagnostic tests benefit category. This is the higher co-payment for services received. 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 reduce the co-payment for the hospital outpatient clinic visit and chest x-rays provided on December 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis, amalgam, extraction, and three resin-based composites provided from February 5, 2021, to March 10, 2021 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis, amalgam, extraction, and resin-based composites. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that services performed by an OON provider are not covered because your healthcare plan does not have OON 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, you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis, amalgam, extraction, and three resin-based composites provided from February 5, 2021, to March 10, 2021 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a venogram, current procedural terminology (CPT) code
75820, of the lower extremity.
You asked the Plan to pre-approve a venogram of the lower extremity. You say that the requested Venogram of
the lower extremity is medically necessary. The Plan denied your request. The Plan says the requested
Venogram of the lower extremity is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a venogram of the lower extremity. Our
reviewer says that the requested Venogram of the lower extremity is not medically necessary. Our physician
reviewer found the enrollee has swelling in the lower extremity. A lower extremity ultrasound was performed
that does not demonstrate any thrombus or Baker's cyst. The medical record states that the desired test is a
Magnetic resonance venography (MRV). The requested test is a venogram. The medical necessity and
reasonableness, as defined by Medicare rules, of the requested test is not supported by the medical records.
The elements of the coverage rule are not satisfied. The requested service cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a venogram of the lower extremity have not been met. Therefore, we decided
that the Plan does not have to pre-approve a venogram, current procedural terminology (CPT) code 75820, of
the lower extremity.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99310) provided on August 31, 2020.

You asked the Plan to pay for the evaluation and management service. You say that the service should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on August 5, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99310) provided on August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99204) unlisted supplies and materials used in non-surgical procedures (99070) chiropractic extraspinal manipulative treatment (98943) Therapeutic procedure (97112) provided January 26, 2021 to February 4, 2021.You asked the Plan to pay for the chiropractic services. You say that you were under the impression that with the prior authorization that the service would be covered. You should be reimbursed for the full amount because the prior authorization allowed you 3 visits and you only used 2.The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor.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 the outpatient office visit (99204) unlisted supplies and materials used in non-surgical procedures (99070) chiropractic extraspinal manipulative treatment (98943) Therapeutic procedure (97112) provided January 26, 2021 to February 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the myocardial perfusion imaging provided by an out-of-network provider on November 6, 2020.

You asked the Plan to pay for the myocardial perfusion imaging. You say that the medical records support the service, and the claim should be reprocessed for payment. The Plan denied your request. The Plan says utilization of network providers is required.

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 myocardial perfusion imaging provided by an out-of-network provider on November 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cataract surgery (66984) rendered by the out of network (OON) provider on January 26, 2021.You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 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 cataract surgery (66984) rendered by the out of network (OON) provider on January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit, and a duplex scan provided on August 26, 2020 by an out of network (OON) provider.You asked the Plan to pay for an outpatient visit and a duplex scan. You say that you would like this claim reprocessed and paid. You say that you were unaware prior authorization was required.The Plan denied your request. The Plan says prior authorization was not obtained 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 an outpatient visit, and a duplex scan provided on August 26, 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 a partial upper denture (D5213), and an obturator prosthesis (D5932) provided from July 14, 2020, through July 21, 2020.You asked the Plan to pay for a partial upper denture, and an obturator prosthesis. You say that the services were medically necessary.The Plan denied your request. The Plan says the services at issue are not covered benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay fora partial upper denture (D5213), and an obturator prosthesis (D5932) provided from July 14, 2020, through July 21, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on January 6,
2021, and January 18, 2021 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the rendering provider is
eligible to provide services to Medicare beneficiaries. The Plan denied your request. The Plan says there are no
records of a prior authorization having been obtained prior to the services being rendered.
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 subsequent nursing facility care provided on
January 6, 2021, and January 18, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete mandibular denture, simple extraction, and 5 surgical extractions, or pay more for the complete maxillary denture provided on January 14, 2021.
You asked the Plan to pay for the complete mandibular denture, and extractions, and to pay more for the complete maxillary denture. You say that you were not aware that the treating provider was out-of-network. The Plan denied your request. The Plan says your dental maximum has been met.
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 Plan offers a $1,000 annual dental benefit maximum. The record shows that you met the annual maximum benefit while processing this claim for the January 14, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete mandibular denture, simple extraction, and 5 surgical extractions, or pay more for the complete maxillary denture provided on January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device provided on October 14,
2020.

You asked the Plan to pay for a pneumatic compression device. You say that the physician prescribed this
device as necessary for the medical safety of the enrollee. The Plan denied your request. The Plan says this
device is not covered by Medicare to prevent deep vein thrombosis in any setting. Payment for this service
would have been included in the facility payment.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device provided on October 14, 2020.