Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
September 16, 2020.
You asked the Plan to pay for the subsequent nursing facility care. 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 services 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 subsequent nursing facility care provided on
September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999) and endodontic therapy
(D3330) provided on November 20, 2020.
You asked the Plan to pay for the preventive procedure and endodontic therapy. You say that you would like
these services covered. The Plan denied your request. The Plan says these services are not covered benefits
under your dental 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 pay for the
preventive procedure (D1999) and endodontic therapy (D3330) provided on November 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alveoloplasty (D7311), extractions (D7210), dental pain
treatment (D9110), dressing placement (D7922), surgical dental procedures (41899), and dentures (D5110)
provided from July 20, 2020, to July 23, 2020.
You asked the Plan to pre-approve alveoloplasty, extractions, dental pain treatment, dressing placement,
surgical dental procedures, and dentures. You say that these services should be considered medical services.
The Plan denied your request. The Plan says these are dental services and are excluded from coverage.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage.
The services you are asking the Plan to pre-approve 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. 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 alveoloplasty (D7311), extractions (D7210), dental pain treatment (D9110), dressing
placement (D7922), surgical dental procedures (41899), and dentures (D5110) provided from July 20, 2020, to
July 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray.

You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the x-ray was not filed until October 26, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the x-ray.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve these out of network services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.

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 office visit to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodic oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on November 19, 2020.
You asked the Plan to reimburse you for the dental services. You say that the deductions from your social security payments for medical insurance has not changed since you changed plans. You say that you should be reimbursed for what was deducted from social security or for the dental services that you received. The Plan denied your request. The Plan says you do not have routine dental coverage. The Plan says that your dental coverage ended on September 30, 2020, before you received these services. The Plan also says that the premiums reflected on your Social Security Administration Benefit Verification Letter are for medical benefits and do not include dental coverage.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to reimburse you 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 reimburse you for the periodic oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for oral exams and dental cleanings (D1110, D0120) provided November 4, 2020.
You asked the Plan to pay for the oral exams and dental cleanings. You say that the services were medically necessary. The Plan denied your request. The Plan says the benefit for these services was exhausted.
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 enrollee received exams and cleanings on January 30, 2020 and June 22, 2020. The benefit of two exams and cleanings was exhausted. Therefore, we decided that the Plan does not have to pay for oral exams and dental cleanings (D1110, D0120) provided November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation and management service (99442) provided on May 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the telephone evaluation and management service. You say that you would like reconsideration because issuers must ensure that enrollees may obtain covered medical and behavioral health services from the Indian healthcare provider at no greater cost to the enrollee than if the service were obtained from network providers and facilities. The Plan denied your request. The Plan says these services were not urgent, emergent or approved in advance.
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 telephone evaluation and management service (99442) provided on May 27, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (73522) provided by an out of network (OON) provider.

You asked the Plan to pay for an OON x-ray. You say that this should be covered. The Plan denied your request. The Plan says this was not authorized.

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 x-ray (73522) provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic screening testing provided to the enrollee
on August 27, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for the health
of the patient are not a benefit
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found no provider records have been submitted for review. Therefore, there is no evidence to support that the
provided services were medically necessary and reasonable to diagnose, treat or otherwise manage the
enrollee's conditions.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for molecular genetic screening testing provided to the enrollee on August 27, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with lesion removal (45385) provided November 11, 2020.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you don't recall being charged for these services in the past. The Plan denied your request. The Plan says the copayment was 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 $225 copayment for each Medicare covered outpatient hospital facility visit for outpatient surgery. You have been asked to pay a $225 copayment for the diagnostic colonoscopy. This service falls within the Outpatient surgery 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 colonoscopy with lesion removal (45385) provided November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the practitioner services provided on July 3, 2020 by an out of network provider.
You asked the Plan to pay for the practitioner services. You say that you rely on the facility to get prior authorization. The Plan denied your request. The Plan says you did not request prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services 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 the practitioner services provided on July 3, 2020 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion services provided to the enrollee from June 1,
2020, to June 29, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the provider is not eligible and has no Medicare ID on file.
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are
enrolled in the Medicare program.
You are not eligible to bill Medicare. The Plan did not pre-approve the services. We found no
exception that would require the plan to pay for these items/services. 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 infusion services provided to the enrollee from June 1, 2020, to June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown provided on November 4, 2020.
You asked the Plan to pay for the crown. You say that you were not advised that this provider became out-of-network with your plan. The Plan denied your request. The Plan says this service is 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. Therefore, we decided that the Plan does not have to pay for the crown provided on November 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.
You asked the Plan to pre-approve a Vertiflex Superion device. 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. 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 Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device is experimental. More research is needed to show that safety and efficacy of the Vertiflex 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 a Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider at a lower cost share rate.

You asked the Plan to pre-approve these out of network services to be provided at a lower cost share rate. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that your out-of-pocket costs may be higher if you use out-of-network providers, except for emergency care, or out-of-network dialysis services.

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 to be provided at the in-network cost share rate. We note that the plan has approved this office visit, however; the requested exception for a lower cost share payment for these services is not met. Therefore, we decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider at a lower cost share rate.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on June 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the genetic testing. You say that the genetic testing was medically necessary The Plan denied your request. The Plan says the non-urgent services were not authorized because the provider is a non-network provider with the enrollee's health 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 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 genetic testing provided on June 7, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 6, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 6, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmology services provided on October 1, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON ophthalmology services. You say that the services in dispute were required to provide the enrollee with optimum care. You say that you extended treatment in good faith, based on the expectation of payment. The Plan denied your request. The Plan says the services in dispute were not urgent, emergent, or approved in advance.
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 ophthalmology services provided on October 1, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal fusion (22840, 63047, 22633, 22853).

You asked the Plan to pre-approve spinal fusion. You say that this is medically necessary. The Plan denied your request. The Plan says this cannot be approved because the enrollee is a smoker.

The Plan follows Medicare rules. Medicare rules say that spinal fusion is covered when medically necessary for an indication listed in the LCD.

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 spinal fusion. Our reviewer says that the requested spinal surgery is not medically necessary at this time. Our physician reviewer found the medical records show that the patient is a smoker and has not had a negative nicotine test. Smoking is a contraindication to spinal fusion. Also, there is no instability demonstrated on flexion and extension x-rays.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal fusion have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal fusion (22840, 63047, 22633, 22853).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on November 13, 2020.
You asked the Plan to pay for the home visit. You say that this care was critical to the enrollee's overall health. You say that the doctor should not be penalized for a facility mistake. The Plan denied your request. The Plan says this provider is not a network provider with 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 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 home visit provided by an out-of-network provider on November 13, 2020.