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

We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and full series x-rays (D0210), completed on February 16, 2021.

You asked the Plan to pay for oral evaluation and full series x-rays. You say that you were not aware the provider was out-of-network. The Plan denied your request. The Plan says services were obtained 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. 

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. Specifically, you received services by an out of network provider. This means the services are not covered under your benefit Plan. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and full series x-rays (D0210), completed on February 16, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a referral to a dentist for TMJ for the enrollee.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says that this request for treatment is denied.

The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and
necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the referral. Our reviewer says that the
requested referral is medically reasonable and necessary. Our physician reviewer found an evaluation to arrive
at a diagnosis of the cause of the enrollee's TMJ pain meets the criteria for coverage, as it does involve care,
treatment, filling, removal or replacement of teeth or the supporting structures of the teeth.

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 referral have been met. Therefore, we decided that the Plan has to preapprove
a referral to a dentist for TMJ for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on January 18, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that prior authorization is not needed for this test. The Plan denied your request. The Plan says no prior authorization was 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 laboratory work provided on January 18, 2021 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 critical care services (99291) provided on June 6, 2020.

You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not
support that 30-74 minutes of critical care services were rendered.

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 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes.

We find that CPT code 99291 is not supported in the record. Specifically, the record does not show that 30-74
minutes of critical care services were rendered on the billed date of service. Based on this information, we
decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided
that the Plan does not have to pay for the critical care services (99291) provided on June 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 18, 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 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 services provided by an out-of-network provider on December 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Cystourethroscopy provided on January 20, 2021.

You asked the Plan to waive the copayment for the Cystourethroscopy. You say that you cannot understand the charge. 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 $250 copayment for Outpatient Surgery. 

You have been asked to pay a $250 copayment for the Cystourethroscopy. The Cystourethroscopy falls within the Outpatient Surgery benefit category. Medicare considers this procedure a surgery. 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 Cystourethroscopy provided on January 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on November 20, 2020, and December 18, 2020.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were not aware that you would owe such high charges unless you also saw the physician the same day. 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 10% coinsurance for Medicare Part B prescription drugs.
You received a Medicare Part B drug on November 20, 2020. The total allowed amount is $2,592 and 10% of that is $259.20. You received a Medicare Part B drug on December 18, 2020. The total allowed amount is $2,544 and 10% of that is $254.40. The total amount you owe is: $513.60. You have been asked to pay the total coinsurance amount of $513.60 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 coinsurance for Medicare Part B drugs provided on November 20, 2020, and December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and bitewing x-ray (D0270) provided on November 4, 2020.

You asked the Plan to pay for the problem focused limited oral evaluation and bitewing x-ray. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services exceed the frequency limitation in your benefit 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, problem focused limited oral evaluation (D0140) and bitewing x-ray (D0270) are each limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on August 18, 2020, and bitewing x-rays (D0274) on September 18, 2020, and your problem focused limited oral evaluation (D0140) and bitewing x-ray (D0270) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and bitewing x-ray (D0270) provided on November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on January 20, 2021.
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that anesthesia services performed in conjunction with facet joint injections are typically not covered.
We looked at the file and Medicare rules. There is no documentation of anxiety or unstable medical issues. The documentation does not support any reasoning why anesthesia would have been necessary during the cervical facet joint injections provided. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an periodic oral evaluation (D0120) and prophylaxis (D1110), provided on December 1, 2020.
You asked the Plan to pay for an oral evaluation and prophylaxis. You say that the services should be covered. The Plan denied your request. The Plan says you obtained services from 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. 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. Specifically, the services you received were obtained by an out-of-network provider. This means they are not covered benefits. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110), provided on December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the maxillary partial denture adjustment (D5421) provided on February 2, 2021.

You asked the Plan to pay for the maxillary partial denture adjustment. You say that you should not be held responsible for this charge. The Plan denied your request. The Plan says that this service is not a covered benefit.

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 has denied this service as not a covered benefit. The EOC clearly lists maxillary partial denture adjustment (D5421) as a covered service. You reasonably believed this service would be covered because it is listed as a covered benefit. Therefore, we decided that the Plan has to pay for the maxillary partial denture adjustment (D5421) provided on February 2, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 18, 2021 by an out of
network (OON) provider.

You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services provided are not a covered benefit.

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 provided on January 18, 2021 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the long term care services provided from October 3, 2020, to November 1, 2020.

You asked the Plan to pay for the long term care services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not improve with skilled care. The Plan also says that the enrollee was not making progress with with skilled therapy and did not have any skilled nursing needs.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the long term care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the long term care services provided from October 3, 2020, to November 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 vaccine provided on February 25, 2021.

You asked the Plan to pay for the COVID-19 vaccine. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the injection must be billed to Original Medicare not the Plan.

Original Medicare pays for the COVID-19 vaccine. The Plan follows the same rules. Therefore, we decided that the Plan does not have to pay for the COVID-19 vaccine provided on February 25, 2021. However, the records show the pharmacy billed the claim to Original Medicare and the claim was paid.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (14301, 14302) provided February 5, 2020.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of codes 14301, & 14302 is described as Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60 sq cm. and Adjacent tissue transfer or rearrangement, any area; each additional 30 sq cm, or part thereof. 

We find that CPT code 14301, & 14302 is not supported in the medical record. Specifically, the operative report indicates that the primary surgeon and appealing physician provided wound closure services.

The operative report describes undermining of tissue and excision of margins that would create a dog ear deformity. The operative note does not describe back cuts to perform tissue rearrangement. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (14301, 14302) provided February 5, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities (97530) provided May 16, 2020.

You asked the Plan to pay for the therapeutic activities. You say that many of the requested services in 2020 are not available on an outpatient basis secondary to the recent COVID-19 virus pandemic. Please review all attached documentation supporting this request and process your claim for payment. The Plan denied your request. The Plan says the records do not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 

We find that CPT code 97530 is not supported in the medical record. Specifically, the records indicate that the service is performed by an occupational therapist assistant in a home health or hospice setting. There is an appropriate Healthcare Common Procedure Coding System (HCPCS) code (G2169) for the billed service. The records show that the plan made multiple attempts to obtain additional information from the provider without success. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities (97530) provided May 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on January 20, 2021.

You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says hearing aids must be purchased through the Plan's hearing aid provider.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the Plan's hearing aid provider. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on January 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the diabetic shoe and insert provided on September 16, 2020.

You asked the Plan to waive the coinsurance for the diabetic shoe and insert. You say that no cost share should have applied to this date of service. You say that this was provided in the office, but you had to use POS 12 for DME. The Plan denied your request. The Plan says the coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for each pair of Medicare-covered therapeutic shoes.

The enrollee has been asked to pay $54.27 for the diabetic shoe and insert.

Service
Allowed Amount
Coinsurance
Member Liability

Diabetic Shoe
$96.04
20%
$19.21

Shoe Insert
$175.32
20%
$35.06

TOTAL:
$54.27

The diabetic shoe and insert falls within the "Diabetes Self-Management Training, Diabetic Services and Supplies" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the diabetic shoe and insert provided on September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray you received on February 3, 2021.

You asked the Plan to pay for the panoramic x-ray. The Plan denied your request. The Plan says that benefit
limit has been exceeded.

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 services are subject to a
benefit limitation. The records show that you were provided a covered panoramic x-ray or full-mouth x-rays on
July 16, 2019. This means that the requested x-ray exceeds the benefit limit. Therefore, we decided that the
Plan does not have to pay for the panoramic x-ray you received on February 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device for use during and after surgery billed to the enrollee for December 16, 2020.

You asked the Plan to pay for this claim as billed. You say that the physician ordered this equipment for the enrollees use during and after surgery. The Plan denied your request. The Plan says Medicare billing criteria are not met.

The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This equipment was used during and after a surgical procedure by the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device for use during and after surgery billed to the enrollee for December 16, 2020.