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

We decided that the Plan does not have to pay the in-network rate for the extraction (D7210) of tooth # 4
provided on December 7, 2020.
You asked the Plan to pay the in-network rate for the dental service. You say that your dentist did not tell you
before your appointment that they were out of network. You also say that you should not be responsible for the
out of network coinsurance. The Plan denied your request. The Plan says the provider in this case is out of
network. The Plan says that extractions performed out of network have a 55% coinsurance. The Plan says that
if you see an out of network dentist, the coinsurance level will apply to the average negotiated in network fee
schedule (INFS) in your area. The Plan says that you are responsible for the difference between the INFS and
dentists' charged fees when visiting an out-of-network dentist. The Plan also says that you did not contact them
prior to the date of service to verify benefits and provider eligibility.
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 and extraction is listed as a covered
service, dental services performed out of network have a higher cost share amount. The record shows that you
did not contact the Plan prior to the date of service to verify the providers eligibility. Therefore, we decided that
the Plan does not have to pay the in-network rate for the extraction (D7210) of tooth # 4 provided on December
7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRA of the head (70544), an MRA of the neck (70548), and an MRI of the brain (70551) performed on February 25 to February 26, 2021. We also decided that the Plan does not have to pay for self-administered drugs (Aspirin, Atorvastatin, Clopidogrel, Duloxetine, Insulin Aspart, Insulin Detemir, and Polyethylene Glycol) provided on February 25 to February 26, 2021.
You asked the Plan to waive the copayment for an MRA of the head, an MRA of the neck, and an MRI of the brain. You say that the requested services were a necessity for your care. The Plan denied your request. The Plan says the correct copayment was 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 $225 copayment for advanced imaging services (not including X-rays). You have been asked to pay a $225 copayment for an MRA of the head, an MRA of the neck, and an MRI of the brain. An MRA of the head, an MRA of the neck, and an MRI of the brain fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 MRA of the head (70544), an MRA of the neck (70548), and an MRI of the brain (70551) performed on February 25 to February 26, 2021.
You also asked the Plan to pay for self-administered drugs. You say that the provider would not let you take any of the self-administered drugs you were already on. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.
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 pay for self-administered drugs (Aspirin, Atorvastatin, Clopidogrel, Duloxetine, Insulin Aspart, Insulin Detemir, and Polyethylene Glycol) provided on February 25 to February 26, 2021.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740) for tooth #18, 19 and 20, inlay - porcelain/ceramic 3+ surfaces (D2630) for tooth #30, core buildup, including any pins when required (D2950) for tooth #18, 19, and 20, and an occlusal guard - hard appliance, full arch (D9944).
You asked the Plan to pre-approve porcelain/ceramic crowns, inlay, core buildup and mouth guard. You say that the services are medically necessary. The Plan denied your request. The Plan says these services are not covered under the enrollee's dental 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 pre-approve crown - porcelain/ceramic (D2740) for tooth #18, 19 and 20, inlay - porcelain/ceramic 3+ surfaces (D2630) for tooth #30, core buildup, including any pins when required (D2950) for tooth #18, 19, and 20, and an occlusal guard - hard appliance, full arch (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional periapical x-ray (D0230) for tooth # 25 provided on February 3, 2021.
You asked the Plan to pay for the dental service. You say that the technician at the provider's office had to take an extra x-ray because the first one did not come out clear. You also say that you should not be liable for the extra x-ray. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan also says that the frequency limit has been exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage periapical x-ray is listed as a covered service, the frequency limit has been exhausted. The record shows that you received a periapical x-ray for tooth # 8 and 25 on the date of service in this case. The record shows that the Plan paid for the periapical x-ray for tooth # 8, thus exhausting the benefit. Therefore, we decided that the Plan does not have to pay for the additional periapical x-ray (D0230) for tooth # 25 provided on February 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neupogen (J1442).
You asked the Plan to pre-approve Neupogen. You say that this drug is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says the enrollee is in a clinical trial that is not a covered
benefit.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in
Original Medicare and the plan cost-sharing for the same services.
In this case, you asked the Plan to pre-approve Neupogen as part of a clinical trial. The Plan does not cover
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to preapprove
Neupogen (J1442).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged evaluation and management service before and/or after direct patient care; first hour (99358), the prolonged evaluation and management service, each additional 30 mins (99359), and the telephone evaluation and management service (99443) rendered by the out of network (OON) provider on February 16, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 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 prolonged evaluation and management service before and/or after direct patient care; first hour (99358), the prolonged evaluation and management service, each additional 30 mins (99359), and the telephone evaluation and management service (99443) rendered by the out of network (OON) provider on February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the sinus augmentation (D7951) provided on January 13, 2021.
You asked the Plan to pay for the dental service. You say that this is not a dental service. You say that this is a medical procedure. You also say that it should be covered any out of network specialist expense. The Plan denied your request. The Plan says the provider in this case does not have a contract with Medicare. The Plan says that if a provider is not enrolled, Medicare will not pay for claims that are submitted. The Plan also says that this claim was denied in both the dental and medical processing system.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the dental service has not been met. Specifically, dental services performed by a provider that is
not enrolled in Medicare are not payable by Medicare. Therefore, we decided that the Plan does not have to pay for the sinus augmentation (D7951) provided on January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on December 16, 2020.
You asked the Plan to pay for CxBladder testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-covered. We looked at the file and Medicare rules. The testing at issue is not covered. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing (0012M) provided on December 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for Ocrevus injection.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider for Ocrevus injection.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery to place a Vertiflex Superion device for the enrollee.
You asked the Plan to pre-approve these services. You say that the patient meets medical necessity criteria for this procedure. The Plan denied your request. The Plan says that experimental and investigational procedures are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The device is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve surgery to place a Vertiflex Superion device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 19, 2020.
You asked the Plan to waive the copayment for the office visit. You say that this was a telehealth visit but it was paid as an in-office visit. You say that your plan documents state there is a $0 copayment for telehealth visits, and you should not have a copayment. 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 $45 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted under Medicare rules).
You have been asked to pay a $45 copayment for the office visit. The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The Plan says that the cost share waiver was only through September 30, 2020. 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 office visit provided on November 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the brain (70553), MRI of lumbar spinal canal and contents (72158), and MRI of cervical spinal canal and contents (72156) provided February 11, 2021.
You asked the Plan to waive the copayment for the MRI of the brain, MRI of lumbar spinal canal and contents, and MRI of cervical spinal canal and contents. You say that you were unaware you would be charged for each MRI separately. The Plan denied your request. The Plan says the total cost share has processed correctly 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 an $80 copayment for Medicare-covered radiological diagnostic services.
You have been asked to pay a total cost share of $240 for the MRI of the brain, MRI of lumbar spinal canal and contents, and MRI of cervical spinal canal and contents (3 MRIs x $80 copayment). These services fall within the Medicare-covered radiological diagnostic services 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 magnetic resonance imaging (MRI) of the brain (70553), MRI of lumbar spinal canal and contents (72158), and MRI of cervical spinal canal and contents (72156) provided February 11, 2021.
Your complaint about potentially receiving misinformation regarding your copayment 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CYP3D6 and MTHFR genetic testing rendered on December 8, 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 the testing is not covered.
The Plan follows Medicare rules. The rules say that CYP2D6 testing must be billed with procedure code 81226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, or 0076U.
The file shows that the CYP2D6 testing was billed with procedure code 81479. This is not the appropriate code for this testing.
The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, CYP3D6 and MTHFR genetic testing, was 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 pay for the CYP3D6 and MTHFR genetic testing rendered on December 8, 2020.
The Plan references Local Coverage Determination (LCD) L36400 in their determination; however, this LCD is not binding for the state of Ohio where the testing was performed and was not used in the MAXIMUS determination.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for radiology services (CPT 71046) provided to the enrollee on November 18, 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 that this was not coded correctly.
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 71046 is "Radiologic examination, chest." We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were supported by the medical records. Our physician reviewer found the documentation supports that a chest X-ray was ordered on 11/18/2020. For telehealth distant site services furnished between January 27, 2020, and June 30, 2020, that are also FQHC qualifying visits, FQHCs must report three HCPCS/CPT codes for distant site telehealth services: the FQHC Prospective Payment System (PPS) specific payment code (GO466, G0467, G0468, G0469, or G0470); the HCPCS/CPT code that describes the services furnished via telehealth with modifier 95; and G2025 with modifier 95. The documentation does not support that the visit on 11/18/2020 was at a distant telehealth site. 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 services have been met. Therefore, we decided that the Plan has to pay for radiology services (CPT 71046) provided to the enrollee on November 18, 2020.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Alphagan P Sol 0.1%.
You asked the Plan to pre-approve the drug. You say that the enrollee's pressures have decreased and remained stable since starting this drug. The Plan denied your request. The Plan says this medication falls under Part D coverage.
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-approve Alphagan P Sol 0.1%.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the occlusal guard - hard appliance, full arch (D9944)
and the occlusal guard - soft appliance, full arch (D9945).
You asked the Plan to pre-approve occlusal guards. You say that your dentist told you that you need a night
guard to protect your teeth. The Plan denied your request. The Plan says the requested items are not covered
under your supplemental 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the
occlusal guard - hard appliance, full arch (D9944) and the occlusal guard - soft appliance, full arch (D9945).
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 July 1, 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 July 1, 2020.