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

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) provided on July 14, 2020.You asked the Plan to pay forthe comprehensive oral evaluation. You say that your previous provided never rendered a complete oral exam. You also say that you needed to see a new dentist because of the issues you had with the previous dentist.The Plan denied your request. The Plan says this service exceeds the maximum allowed per period.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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on October 23, 2018, and your comprehensive oral evaluation (D0150) benefit has been exhausted.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) provided on July 14, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on July 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are
available in-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 has network providers
available who can provide 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 medical services provided to the enrollee by an out-of-network provider
on July 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove foot orthotics for the enrollee.

You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary.The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  

Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forGeneSight testing (81479) provided on July 14, 2020.You asked the Plan to pay forGeneSight testing. You say that this is covered by Medicare.The Plan denied your request. The Plan says the criteria for coverage have not been met.The Plan must follow Medicare rules. Medicare rules say that GeneSighttesting may only be ordered by licensed psychiatrists or neuropsychiatrists.We looked at the file and Medicare rules. The records show that the ordering physician for this test was an internal medicine physician. Based on this information, we decided that Medicare rules for coverage of GeneSight testing have not been met.Therefore, we decided that the Plan does not have to pay forGeneSight testing (81479) provided on July 14, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that you have spills and falls in the bathtub.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 22, 2020, by an OON provider.You asked the Plan to pay fora telephone evaluation and management service. You say that this claim should be reconsidered for payment.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 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 forthe medical services provided on September 22, 2020, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 19, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on August 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approvegenetic testing of catecholaminergic polymorphic ventricular tachycardia (CPVT).You asked the Plan to pre-approvegenetic testing of CPVT. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested testing.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listedabove, are not covered.The genetic testing of CPVT at issue in this appeal is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pre-approvegenetic testing of catecholaminergic polymorphic ventricular tachycardia (CPVT).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from April 10, 2020,to June 8, 2020.You asked the Plan to pay forhome health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this claim was billed with an invalid type of bill for a non-participating Home Health provider and Invalid or Missing FIPS Code.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim was submitted with an invalid type of bill code and without the required FIPS code.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from April 10, 2020, to June 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethree implant supported porcelain/ceramic crowns (D6065 x3) and three prefabricated abutments (D6056 x3).You asked the Plan to pre-approvethe implant supported crowns and prefabricated abutments. You say that these services are medically necessary.The Plan denied your request. The Plan says these services are not covered benefits under the enrollee's benefit package.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-approvethree implant supported porcelain/ceramic crowns (D6065 x3) and three prefabricated abutments (D6056 x3).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide power wheelchair, accessories, seat elevation system and
upgraded electronics.
You asked the Plan to provide Electronic connection (E2311), Expandable controller harness (E2313), and
Expandable controller (E2377), power seat elevation system (E2300), joystick (K0108). You say that you need
a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says power seat elevation
systems are not covered by Medicare and the upgraded electronics are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that options and accessories for wheelchairs are covered if
the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is
medically necessary.
The electronic upgrades cannot be covered as it is not medically necessary to control the three approved power
options through the joystick (drive interface). Power seat elevation systems are not covered by Medicare or the
Plan. The push button and joystick touch screen are part of the requested controller and cannot be requested
separately. Therefore, we decided that the Plan does not have to provide power wheelchair, accessories, seat
elevation system and upgraded electronics.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan does not have to waive the cost share charged for services provided February 26,
2020, and March 4, 2020.
You asked the Plan to waive the copayments for physical therapy provided on the dates in question. You say
that you feel the copayment charged is expensive. The Plan denied your request. The Plan says these
copayments were charged based on the services provided and the Plan contract agreement. Maximus partially
overturned the Plans denial. The Plan requested a reopen and provided additional information.
The Plan is correct in this case. 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 $40 copayment for outpatient therapy services. You have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share
charged for services provided February 26, 2020, and March 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCalquenceYou asked the Plan to pre-approvethe Calquence. You say that the requested drug is medically necessary.The Plan denied your request. The Plan says they do not administer any Part D benefits for the enrollee.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveCalquenceBenefits for the Calquencemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe GeneSight testing provided on February 12, 2020.You asked the Plan to pay forthe GeneSight testing. You say that you would like the plan to reconsider their denial.The Plandenied your request. The Plan says the services provided are not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that GeneSight testing may only be ordered by licensed psychiatrists or neuropsychiatrists contemplating an alteration in neuropsychiatric medication for patients diagnosed with major depressive disorder (MDD) who are suffering with refractory moderate to severe depression (based upon DSM-V criteria) after at least one prior neuropsychiatric medication failure.We looked at the file and Medicare rules. Review of the file shows that this testing was ordered by a family medicine doctor and not a licensed psychiatrist or neuropsychiatrist. Based on this information, we decided that Medicare rules for coverage of the GeneSight testing have not been met.Therefore, we decided that the Plan does not have to pay forthe GeneSight testing provided on February 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), intraoral periapical X-rays (D0230 and D0220), a prophylaxis procedure (D1110), and an unspecified preventive procedure (D1999) performed on June 1, 2020.
You asked the Plan to pay for a periodic oral evaluation, intraoral periapical X-rays, a prophylaxis procedure, and an unspecified preventive procedure. You say that you don't understand why your dental care is being denied. The Plan denied your request. The Plan says rules for payment have not 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. The Plan covers a periodic oral evaluation, intraoral periapical X-rays, a prophylaxis procedure, and an unspecified preventive procedure when these services are received from a network dentist. We looked at the case file and Medicare rules. In this case, the services in question were not received from a network dentist. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, intraoral periapical X-rays, a prophylaxis procedure, and an unspecified preventive procedure have not been met. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), intraoral periapical X-rays (D0230 and D0220), a prophylaxis procedure (D1110), and an unspecified preventive procedure (D1999) performed on June 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for laboratory services and a biopsy and does not have to waive the coinsurance for diagnostic radiology provided from August 5, 2020, to August 17, 2020.
You asked the Plan to waive the copayments for laboratory services and a biopsy and to waive the coinsurance for diagnostic radiology. You say that you did not realize how much all of the charges would amount to. 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 $6 copayment for laboratory services and 20% coinsurance for each diagnostic imaging service. Your contract with the Plan also clearly says that you must pay a $450 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received laboratory services and a biopsy and diagnostic radiology provided from August 5, 2020, to August 17, 2020. Therefore, you are responsible to pay your share of the cost-sharing charges. The total amount you owe is: $1,903.94. You have been asked to pay the total amount of $1,903.94 for laboratory services, diagnostic radiology and a biopsy. Laboratory services and diagnostic radiology fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A biopsy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for laboratory services and a biopsy and does not have to waive the coinsurance for diagnostic radiology provided from August 5, 2020, to August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe bone graft at time of implant placement (D6104 x 2), the conscious sedation (D9074), and the 25-year full-mouth limited warranty (D9999) provided on September 6, 2019.You asked the Plan to reimburse you forthe 2 bone graft at time of implant placement, the conscious sedation, and the 25-year limited warranty. You say that you had a dental rider when you received the services. You say that you had a dental emergency. You say that the provider office advised that most of the services would be covered. You say that you were lied to and misinformed. You also say that you did whatever was needed for the pain to stop.The Plan denied your request. The Plansays that the bone graft at timeof placement does not match the code that was submitted. The Plan also says conscious sedation and 25-year full mouth limited warranty 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. Additionally, providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code D6104 is bone graft at time of implant placement.Additionally, the CPT Code Manual definition of Code D9074 does not exist.

We find that CPT code D6104 is not supported in the medical record. Specifically, no implants were placed on the date of service. We also find that CPT code D9074 is not supported as it is not a valid CPT code. Based on this information, we decided that Medicare rules for coverage of bone graft at time of implant placementand the conscious sedationhave not been met.Additionally, though the Plan offers a dental benefit in excess of Medicare coverage, the 25-year limited warranty are not among those covered under this benefit.Therefore, we decided that the Plan does not have to reimburse you forthe bone graft at time of implant placement (D6104 x 2), the conscious sedation (D9074), and the 25-year full-mouth limited warranty (D9999) provided on September 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eye wear you purchased July 30, 2020.You asked the Plan to pay forthe eye wear. You say that you feel these services should be covered based onyour medical condition.The Plan denied your request. The Plan says you have exhausted your benefit limit for these services.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a pair of eyeglasses once every 24 months.
We looked at the fileand the Plan's rules. The file indicates that you previously purchased a pair of eyeglasses using the Plan's benefit in July 2019. Therefore, you have exhausted your Plan benefit until July 2021 and no reimbursement is due. Based on this information, we decided that the Plan's rules for coverage of the eye wear have not been met.Therefore, we decided that the Plan does not have to pay forthe eye wear you purchased July 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), and bitewings (D0274) provided on August 24, 2020.
You asked the Plan to pay for the intraoral periapical x-rays and bitewings. You say that your plan guide states that 2 cleanings and exams and 1 dental x-ray are covered per year. You also say the Plan does not specify that only full moth x-rays are covered. The Plan denied your request. The Plan says these services are not covered by the 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 first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), and bitewings (D0274) provided on August 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diagnostic mammography services coded 77065 provided on February 5, 2020.You asked the Plan to pay forthe diagnostic mammography 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 claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.In this case, the MUE for CPT code 77065 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the diagnostic mammography services have not been met.Therefore, we decided that the Plan does not have to pay forthe diagnostic mammography services coded 77065 provided on February 5, 2020.