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

We decided that the Plan does not have to pay for endodontic therapy, premolar tooth (excluding final restoration) (D3320) provided on February 27, 2020 by an out-of-network provider.

You asked the Plan to pay for the dental services. You say that based on your enrollment guide this procedure should be covered. The Plan denied your request. The Plan says the service is not a covered benefit under 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. This service/dental code is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for endodontic therapy, premolar tooth (excluding final restoration) (D3320) provided on February 27, 2020 by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that on the date of service you were attending a live performance when you began to experience a sudden asthma attack with an acute shortage of breath. You say that the theater personnel called 911 and when the responders arrived they immediately began treating you. You stated that after treatment your symptoms began to resolve over time and eventually you were able to get to your car to follow up with your treating doctor. You say that you did not require ambulance transportation at that time. You stated that your claim was denied because you were not transported however the responders did provide treatment for you. 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 24, 2019. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for complete upper denture (D5110) and complete lower denture (D5120).
You asked the Plan to pay for the dental services. You say that the dentures you have do not fit properly. They rub your gums and you cannot eat with them and you are requesting reconsideration for new dentures. The Plan denied your request. The Plan says this request exceeds the benefits frequency limitation
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 contract says that dentures are covered once every 5 years. The records show that a complete lower denture was received on February 22, 2017 and a complete lower denture on January 17, 2018. 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 complete upper denture (D5110) and complete lower denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygenator assembly and operation services (CPT 99190) provided to the enrollee on April 9, 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 services are not authorized because they are part-A benefit while an inpatient hospital admission and are included in the facility DRG payment.
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 99190 is "Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour." We find that CPT code 99190 is not supported in the medical record. Specifically, payment for this code is included in the payment to the facility. 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 oxygenator assembly and operation services (CPT 99190) provided to the enrollee on April 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cardiac device evaluation provided on January 2, 2020.
You asked the Plan to waive the copayment for the cardiac device evaluation. You say that if you knew you would be charged you would have cancelled the appointment. You say that you should have been notified prior to the service. The Plan denied your request. The Plan says the copayment 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 $35 copayment per visit to a specialist. Covered services include consultation, diagnosis, and treatment by a specialist. You have been asked to pay a $35 copayment for the cardiac device evaluation. The cardiac device evaluation falls within the "Physician/Practitioner services, including doctor's office visits" 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 cardiac device evaluation provided on January 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a bone density scan (77080) provided on February 11, 2020.
You asked the Plan to pay for the bone density scan. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not preauthorized or emergent. There were network providers available.
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 service 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 a bone density scan (77080) provided on February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (99292) provided on November 6, 2019. 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 that code 99292 was billed without the primary procedure code. According to coding guidelines, add-on codes should not be billed as a stand-alone code. Plans must follow Medicare rules. Medicare rules say that for the same date of service only one physician of the same specialty in the group practice may report code 99291 (primary) with or without code 99292 (add-on), and the other physician(s) must report their critical care services with CPT code 99292. We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the critical care services have been met. Specifically, an emergency medicine physician billed for code 99291, which was paid for by the Plan on December 15, 2019. A physician assistant practicing for the same emergency medicine medical group then billed for code 99292. Only one physician of the same specialty in the group practice may report code 99291 for the same date of service. All others must report critical care services as 99292. Based on the claim submitted, Medicare billing criteria have been met. Therefore, we decided that the Plan has to pay for the critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (99292) provided on November 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 you required minimal assistance with bed mobility, transfers, basic activities of daily living, and dressing. The documentation does not support that you require an intensive rehabilitation therapy program. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for core buildup including any pins (D2950) and porcelain crown (D2740) provided February 3, 2020 to February 12, 2020.
You asked the Plan to pay for the dental services. You say that you made it very clear you only wanted work covered by the plan. The dentist had started and finished the approved crowns and did not tell you the rest of the crowns were not covered. The Plan denied your request. The Plan says these services exceeds the annual maximum 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 allows a $2,500 benefit maximum. The records show that the benefit maximum had been met prior to the processing of this claim. 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 core buildup including any pins (D2950) and porcelain crown (D2740) provided February 3, 2020 to February 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that on the date of service you woke up experiencing pressure in your chest and shortness of breath. You say that you called 911 and an ambulance was dispatched to your home. You stated that by the time the ambulance had arrived, the pressure in your chest had ceased and you were only experiencing shortness of breath. The ambulance responders then evaluated you and checked your vitals. You say that you were advised by the responders that your blood pressure was high and that it was your decision whether you wanted to be transported to the hospital or not. You say that since your other vital signs were normal, you decided that you would go to the hospital later in the morning. You asked the Plan to reconsider their denial because the chest pressure you were experiencing had subsided by the time the ambulance had arrived. You say that you were unaware that the ambulance would not be covered if you were not transported to the hospital. 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 November 27, 2019. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided to the enrollee on January 1, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that the payment you received was only 45%. You state the benefit details do not indicate that out-of-network providers will have the rates reduced to any usual customary rate. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2020 benefits.
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. Since the dentist is out-of-network, the Plan pays according to a maximum allowable fee schedule and member is responsible for all the fees in excess of this amount from the billed amount. As per the Plan benefits, since the provider was out-of-network, the difference of billed amount and allowed/ paid amount became member's responsibility. The allowable amounts are as per the Medicare guidelines and cannot be changed by the Plan. Therefore, we decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided to the enrollee on January 1, 2020 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the laser refractive surgery provided on November 25, 2019 by an out-of-network provider. You asked the Plan to pay for the laser refractive surgery. You say that you spoke with the Plan and they said it was covered. The Plan denied your request. The Plan says they reviewed your call history and found on October 8, 2019. The Plan states you called prior to your date of service stating you went to the provider to have your routine yearly and your prescription changed. The Plan states you requested a script from the provider for glasses and the provider stated there would be a $50 charge and you say you saw you had refractions in your benefits. The Plan states their representative advised you that you would pay out-of-pocket for refraction/ glasses fee and then can request the money back. The Plan states that you did not mention the upcoming laser cataract surgery, and there was no request for information for this procedure or what the out-of-pocket may be.
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. We looked at the file and the Plan's rules. This service is not covered under Medicare or the Health Plan. Therefore, we decided that the Plan does not have to pay for the laser refractive surgery provided on November 25, 2019 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor.
You asked the Plan to pre-approve a Freestyle Libre 14 day sensor. You say that the item is medically necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that CGM devices are covered when specific criteria is met. 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 Freestyle Libre 14 day sensor. Our reviewer says that the item is not medically necessary. Our physician reviewer found you are not insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. 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 Freestyle Libre 14 day sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve routine transportation. You say that you need additional rides to complete treatment. The Plan denied your request. The Plan says the denial of authorization for additional routine transportation is correct, because routine transportation beyond 60 one-way trips per calendar year is not covered by the Plan.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for periodontal scaling and root planing - four or more teeth per quadrant (D4341 x 2) provided on March 10, 2020. You asked the Plan to pay for the dental services. You say that you were not aware you could only have the services done on two (2) quadrants per visit. The Plan denied your request. The Plan says that you exhausted your benefit. The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The EOC does not specify what is covered for dental services and more specifically it does not list how many periodontal scaling and root planing - four or more teeth per quadrant procedures are allowed. There is no other documentation provided to verify what is covered. The health plan contract says that the Plan pays up to $1,000 every year for preventive and comprehensive services. This annual limit is for all dental services combined: preventive, comprehensive and dentures. Therefore, we decided that the Plan has to pay for periodontal scaling and root planing - four or more teeth per quadrant (D4341 x 2) provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 14 day sensor.
You asked the Plan to pre-approve Freestyle Libre 14 day sensor. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested item.
The Plan must follow Medicare rules. Medicare rules say that diabetic supply codes for CGMs are only covered when you meet criteria for the CGM. We looked at the file and Medicare rules. Review of the file does not support that you take insulin three times a day and check your sugars four or more times per day. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre 14 day sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14 day sensor.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there is no need for skilled services. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. She does not have complex wound care or other ongoing SN need that requires a SNF stay. She does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. She does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for portable oxygen concentrator (E1392)
provided on October 25, 2019 by an out-of-network provider.
You asked the Plan to waive the coinsurance for the DME. You say that you are requesting reimbursement of
services rendered. The Plan denied your request. The Plan says the claim has been reimbursed 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).
You received the DME products in advance from an out-of-network provider. The Plan has concluded the
claim was processed and reimbursed correctly per you DME benefits. You were asked to pay 20% coinsurance
for the DME. 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 portable oxygen concentrator (E1392)
provided on October 25, 2019 by an out-of-network provider.