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

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on December 9, 2020.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you feel this service should be covered. The Plan denied your request. The Plan says this service exceeds the coverage limits.

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, you are limited to two oral examinations per calendar year. The record shows that you received oral exams on July 14, 2020, and November 5, 2020 and your oral examinations benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (95076) provided October 5, 2020.

You asked the Plan to pay for the physician services. You say that the service was medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the allowable.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code 95076 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met.

Therefore, we decided that the Plan does not have to pay for physician services (95076) provided October 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) and tooth extractions (D7140) provided on December 28, 2020.

You asked the Plan to pay for the x-ray and extractions. You say that your provider quoted you a large sum of money for the requested services, so you called around to 10 other network dentists. You say that none of them were taking new patients, so you used an out-of-network provider who offered a better rate. This provider does not accept insurance of any kind, but you feel the Plan should reimburse you because you found better prices. The Plan denied your request. The Plan says out-of-network dental care is not covered by the Plan. In addition, the Plan investigated your claim of network deficiency and found that there were providers available who could have provided this care.

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 does not cover out-of-network dental care.

Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received out-of-network are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) and tooth extractions (D7140) provided on December 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), 2D oral/facial photographic image (D0350), and two preventive procedures (D1999 x2) provided from December 1, 2020, to December 29, 2020.

You asked the Plan to pay for the comprehensive oral evaluation, 2D oral/facial photographic image, and two preventive procedures. The Plan denied your request. The Plan says 2D oral/facial photographic image and unspecified preventive procedure are not covered benefits. The Plan also says that the comprehensive oral evaluation exceeds the benefit allowance.

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, 2D oral/facial photographic image and unspecified preventive procedure are not among those covered under this benefit. The contract says that comprehensive oral evaluation (D0150) is limited to once per 36 months. The record shows that you received a comprehensive oral evaluation (D0150) on December 29, 2020, and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), 2D oral/facial photographic image (D0350), and two preventive procedures (D1999 x2) provided from December 1, 2020, to December 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for cone beam CT image capture with limited field of view (D0380) provided on December 15, 2020.

You asked the Plan to pay for the dental service. You say that this service should be covered because it is an x-ray. You also say that the x-ray was necessary to diagnose the tooth. The Plan denied your request. The Plan says cone beam CT image capture with limited field of view 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for cone beam CT image capture with limited field of view (D0380) provided on December 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on December 1, 2020 by an OON provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that the rendering physician depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance company. The Plan denied your request. The Plan says the service was rendered by an OON provider. The Plan also says that prior authorization was not 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 subsequent nursing facility care provided on December 1, 2020 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the dexamethasone sodium phosphate 1mg injection (J1100) and the destruction by neurolytic agent, of the paravertebral facet joint nerve(s) (64635) provided on December 7, 2020.

You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the services provided.

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 $1,250 deductible. This is the amount you have to pay out-of-pocket before the Plan will pay their share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. The deductible does not apply to some services, including Medicare Part B drugs and primary care physician or specialist visits (deductible could apply for additional services performed on the same day in the physician's office). In addition, you are required to pay a 20% coinsurance for in-network Medicare Part B drugs and a $175 copay after the deductible is met for each in-network outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. 

You have been asked to pay $138.36 which includes a $138.10 deductible for the outpatient surgery provided, as you had not previously met the yearly deductible until the claim was submitted for this service. Additionally, this includes a $.26 coinsurance ($1.04 x 20%) for the Medicare Part B drug provided. 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 cost share for the dexamethasone sodium phosphate 1mg injection (J1100) and the destruction by neurolytic agent, of the paravertebral facet joint nerve(s) (64635) provided on December 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for paravertebral blocks (64461) provided on August 20, 2020.

You asked the Plan to pay for paravertebral blocks. You say that this was billed correctly. The Plan denied your
request. The Plan says the units billed exceed MUE.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 64461 is 1. You billed 2 units of this code, exceeding the MUE. Based on
this information, we decided that Medicare rules for coverage of paravertebral blocks have not been met.
Therefore, we decided that the Plan does not have to pay for paravertebral blocks (64461) provided on August
20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided on September 26, 2019.

You asked the Plan to pay for the services provided. You say that the claim was originally submitted to Medicare. The Plan denied your request. The Plan says it is the providers responsibility to check the enrollee's benefits and eligibility.

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 services provided was not filed until December 9, 2020. 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 the nursing facility care provided on September 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placements of an implant body (D6010), custom abutments (D6057) and abutment supported crowns (D6058) for teeth #13, #14 and #26.

You asked the Plan to pre-approve the implants and abutments. You say that there is nothing to anchor the partials to, and the implants and abutments are necessary. The Plan denied your request. The Plan says the documentation provided does not demonstrate that there is a medical condition that would be alleviated by implants that could not be corrected by other functional alternatives for prosthetic replacement. A partial denture would be a more cost-effective treatment for the missing teeth.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the implants and abutments when the services are medically necessary and reasonable. 

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 implants and abutments. Our reviewer says that there is no medical necessity for the requested procedures, given the limitations of the Policy for implant restoration. Our physician reviewer found that the Plan limitations provide that implants are allowable only when there is no other functional method of tooth replacement. In this instance, the replacement of these teeth could be achieved with a removable partial denture at a lower cost. There are sufficient remaining natural and restored teeth to allow for a removable appliance. The remaining upper teeth are restored and despite existing bridgework, a partial denture could reasonably be constructed. There is no medical necessity for the implants and abutment work under this Policy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the implants and abutments have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical placements of an implant body (D6010), custom abutments (D6057) and abutment supported crowns (D6058) for teeth #13, #14 and #26.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing provided on January 11, 2021.

You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your request. The Plan says this testing was not billed with the appropriate coding.

The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT code 81479 for date of service January 11, 2021. 

We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing provided on January 11, 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 the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee has a past medical history of hypertension, kidney disease, chronic obstructive pulmonary disease (COPD), and neuropathy and is living at home with increasing weakness. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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 pay for the skilled nursing facility (SNF) continued stay provided from August 21, 2020, to September 19, 2020.

You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive any skilled services on these dates of service.

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 pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) continued stay provided from August 21, 2020, to September 19, 2020.
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 the stay is medically necessary. The Plan denied
your request. The Plan says the stay 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 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 complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
surgical treatment of a hip fracture after a fall. Medical conditions are stable. There are no complex nursing or
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. You do require physical and
occupational therapy but there is no documented need for an intensive rehabilitation program. Medically
necessary services can be provided in a different level of care. There is not a reasonable expectation that you
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an
IRF.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for topical application of fluoride (D1208) provided on July 9, 2020, and December 11, 2020.

You asked the Plan to pay for topical application of fluoride (D1208). You say that you believe these services should be covered. The Plan denied your request. The Plan says these services are inconsistent with the enrollee's age.

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, preventive services, such as topical application of fluoride, is not covered by the Medicare supplemental portion of the Plan. Therefore, we decided that the Plan does not have to pay for topical application of fluoride (D1208) provided on July 9, 2020, and December 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a knee brace provided by a participating provider on January 5, 2021.

You asked the Plan to waive the coinsurance for durable medical equipment. You say that you were told that you would not owe anything for the knee brace. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for durable medical equipment/in-network. 

You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The total allowed amount is $500.34. The total amount you are being asked to pay is $100.07 ($500.24 x 20% = $100.07). Durable medical equipment falls within the durable medical equipment/in-network 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 a knee brace provided by a participating provider on January 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 3, 2020.

You asked the Plan to pay for the ambulance services. You say that on this day you were diagnosed with Covid and the medics treated you in place. 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 December 3, 2020. 

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 provided on December 3, 2020.