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

We decided that the Plan does not have to pay for gingival irrigation (D4921), an office visit for observation (D9430), an unspecified adjunctive procedure (D9999), and localized delivery of antimicrobial agents (D4381 x2) provided on February 24, 2021.

You asked the Plan to pay for gingival irrigation, an office visit for observation, an unspecified adjunctive procedure, and localized delivery of antimicrobial agents. You say that you need these services, and you want the Plan to pay. 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 for gingival irrigation (D4921), an office visit for observation (D9430), an unspecified adjunctive procedure (D9999), and localized delivery of antimicrobial agents (D4381 x2) provided on February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleaning (D1110), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on December 1, 2020.
You asked the Plan to pay for the dental services. You say that you purchased an additional coverage for 2 extra cleanings per year. You say that you called the plans and were advised that the plans were the same. You say that you were never notified that the plans were the same. You say that you have been receiving 4 cleanings per year since 2014. You also say that you feel that this plan has been deceitful. The Plan denied your request. The Plan says cleanings are limited to once every 6 months. The Plan says that the frequency limit has been exceeded. The Plan also says that periapical x-rays 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, 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 cleaning (D1110), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on December 1, 2020.
Your complaint about being misled by a plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110), the periodic oral evaluation
(D0120), the bitewing x-rays (D0274), the 3-surface amalgam (D2160), the 2-surface amalgam (D2150), and
the pin retention (D2951 x 2) provided from January 20, 2021, to February 4, 2021.
You asked the Plan to pay for the dental services. You say that you were enrolled in the optional supplemental
dental rider on the dates of service in this case. You also say that the Plan denied your request. The Plan says
the provider in this case is out of network. The Plan says that out of network providers may bill you for charges
above the amount that the plan pays, even for the services that are listed with a $0 copayment. The Plan also
says that pin retention is not listed as a covered 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 pin retention is not among those
covered under this benefit. The Evidence of Coverage clearly states that any services not listed are not covered.
Additionally, out of network providers may bill you for any amount over what the plan pays.
Date of Service CPT Code Billed Amount Allowed Amount Difference Plan Paid Your Responsibility
1/20/2021 D1110 $88 $41 $47 $41 $47
D0120 $46 $19 $27 $19 $27
D0274 $65 $26 $39 $26 $39
2/4/2021 D2160 $232 $78 $154 $78 $154
D2951 $37 $0 $37 $0 $37
D2150 $306 $63 $142 $63 $142
D2951 $37 $0 $37 $0 $37
TOTAL: $483 $227 $483
This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we
decided that the Plan does not have to pay for the prophylaxis (D1110), the periodic oral evaluation (D0120),
the bitewing x-rays (D0274), the 3-surface amalgam (D2160), the 2-surface amalgam (D2150), and the pin
retention (D2951 x 2) provided from January 20, 2021, to February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services (99205) provided January 28, 2021.

You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid CPT code for the services provided.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 99205 is Office or other outpatient visit for the evaluation and management of a new patient. 

We find that CPT code 99205 is not supported in the medical record. Specifically, the services at issue are observation services. There is a more appropriate CPT code that describes these services. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met.

Therefore, we decided that the Plan does not have to pay for outpatient services (99205) provided January 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from September 26, 2019, through September 30, 2019.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the corrected claim exceeds 12 months or 1 calendar year from the date the services were furnished.

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 physician's services was not filed until February 20, 2021. 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 physician's services provided from September 26, 2019, through September 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a
participating provider on December 7, 2020, to December 10, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with
these charges. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $393
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.

You have been asked to pay a $393 copayment per day for days 1-3 for an inpatient hospital stay. The total
amount you are being asked to pay is $1,179 ($393 x 3 days = $1,179). The correct copayment has been
applied to the inpatient stay that was provided. An inpatient hospital stay falls within the inpatient hospital care
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 an inpatient hospital stay
provided by a participating provider on December 7, 2020, to December 10, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on October 16, 2020 by an OON provider.

You asked the Plan to pay for the home visit. You say that you provide urgent/emergent care in the home which does not require prior authorization, nor does it require a referral.The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The Plan also says that services are not covered by the enrollee's plan when performed by a non-participating 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 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 on October 16, 2020 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Testosterone pellets (S0189) provided on October 27,
2020.

You asked the Plan to pay for the Testosterone pellets. You say that the enrollee presents all of the criteria
based on which the drug should be covered by the Plan. The Plan denied your request. The Plan says the denial
of payment for these services is correct, because the billed code is not valid for Medicare purposes and is not
covered.

The Plan must follow Medicare rules. Medicare rules say that procedure code S0189 is not valid for Medicare
purposes and is not payable.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Testosterone pellets have not been met. Therefore, we decided that the Plan does not have to
pay for the Testosterone pellets (S0189) provided on October 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EEG, a hearing test, and outpatient mental health services provided by a participating provider on October 27, 2020.

You asked the Plan to waive the copayment for an EEG, a hearing test, and outpatient mental health services. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct copayments have been applied.

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 $50 copayment for outpatient diagnostic tests/diagnostic tests, a $40 copayment for hearing services, and a $40 for outpatient mental health care. 

You have been asked to pay a $50 copayment for an EEG and a $40 copayment for hearing services.

You have been asked to pay $33.12 which is less than your copayment amount of $40 for outpatient mental health services. The total amount you are being asked to pay is $123.12 ($50 + $40 + $33.12 = $123.12). An EEG services falls within the outpatient diagnostic tests/diagnostic tests benefit category. A hearing test falls within the hearing services benefit category. Outpatient mental health services falls within the outpatient mental health care 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 an EEG, a hearing test, and outpatient mental health services provided by a participating provider on October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) rendered by the out of network (OON) provider on February 21, 2020.

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 psychiatric diagnostic evaluation (90791) rendered by the out of network (OON) provider on February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on June 26, 2020 and June 27, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 95819 is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 95819 is electroencephalogram (EEG); including recording awake and asleep. 

We find that CPT code 95819 is not supported in the medical record. Specifically, there is no documentation of an EEG, including awake and asleep, for the dates of service at issue. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the testing services rendered on June 26, 2020 and June 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fillings for teeth # 27 and 31 provided on March 17, 2021.
You asked the Plan to pay for the dental services. You say that you were told that the fillings would be covered. The Plan denied your request. The Plan says fillings 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, the fillings are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the fillings for teeth # 27 and 31 provided on March 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need more than what a skilled nursing facility (SNF) can provide. The Plan denied your request. The Plan says these needs can be met at a lower level of care, such as a SNF.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the health plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen (15) hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the services you require can be given in a Long-Term Care Facility.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular-respiratory risk assessment testing / panels (CPT code(s): 81404 and 81479) provided to the enrollee on January 7, 2021.
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Review of the file show that the enrollee received cardiovascular-respiratory risk assessment testing / panels (CPT code(s): 81404 and 81479) on January 7, 2021. Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.
Therefore, we decided that the Plan does not have to pay for cardiovascular-respiratory risk assessment testing /
panels (CPT code(s): 81404 and 81479) provided to the enrollee on January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99213) provided to the enrollee on March 4, 2021, by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility. The Plan states the provider should have verified the enrollee's eligibility, health benefits and obtained authorization prior to the enrollee's visit before providing services to the enrollee as outlined on the enrollee's identification card.
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 office visit (CPT code 99213) provided to the enrollee on March 4, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-rays of the shoulder, collarbone, and hands you had on July 22, 2020
You asked the Plan to waive the copayment for the x-rays. You say that you should not be charged for these services. The Plan denied your request. The Plan says you were charged this copayment 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 $35 copayment for x-rays.
You have been asked to pay a $35 copayment for the x-rays. 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 x-rays of the shoulder, collarbone, and hands you had on July 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional PT visits.
You asked the Plan to pre-approve additional PT visits. You say that you need the additional PT visits for left knee pain following a total knee arthroplasty. You say that you would not be successful in a home exercise program. The Plan denied your request. The Plan says you do not need services at the level of complexity and sophistication required to be performed by a licensed therapist. Services that do not require the performance or supervision of a therapist are not skilled and are not considered reasonable or necessary therapy services, even if they are performed or supervised by a qualified professional.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve additional PT visits. Our reviewer says
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific
and effective therapy for your condition beyond what was approved by the health Plan. You have had
prior extensive therapy and the records do not demonstrate that the unique skills of a professional therapist are
required to safely and effectively provide treatment, that the services can be safely and effectively performed
only by a therapist, or for physical therapy, by or under the supervision of a therapist. You have been instructed
in a home exercise program. The requested services are not part of a maintenance program, are the specialized
skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to
maintain your current condition or to prevent or slow further deterioration
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does
not have to pre-approve additional PT visits.