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

We decided that the Plan does not have to pay forcomprehensive oral evaluation -new or established patient (D0150), prophylaxis -adult (D1110), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), bone replacement graft for ridge preservation -per site (D7953) and crown -porcelain/ceramic (D2740) provided from September 11, 2019 through October 22, 2019 by an out-of-network provider.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you do not have out-of-network 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.Comprehensive oral evaluation -new or established patient (D0150) and prophylaxis -adult (D1110) are not covered because they were provided by an out-of-network provider. Furthermore, extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), bone replacement graft for ridge preservation -per site (D7953) and crown -porcelain/ceramic (D2740) are not listed in your EOC as a covered benefit; therefore, the services are not covered.Therefore, we decidedthat the Plan does not have to pay forcomprehensive oral evaluation -new or established patient (D0150), prophylaxis -adult (D1110), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), bone replacement graft for ridge preservation -per site (D7953) and crown -porcelain/ceramic (D2740) provided from September 11, 2019 through October 22, 2019 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on February 5, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you exhausted your 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. You exhausted your benefit because you had the same service less than a year ago on February 27, 2019. Therefore, we decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (K0821) and accessories (E2365).
You asked the Plan to pre-approve the power wheelchair and accessories. You say that you would like reconsideration because the equipment is medically necessary. The Plan denied your request. The Plan says power wheelchairs for use outside the home are not a covered benefit. The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0821)and accessories (E2365).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesiology services rendered on August 23, 2019.
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 claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 25 for a birthing center; however, the file shows that the services were performed in an ambulatory surgical center. Therefore, we decided that the Plan does not have to pay for the anesthesiology services rendered on August 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on January 13, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you were not enrolled in a dental plan for this date of service.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. According to enrollment records your dental plan terminated on December 31, 2018. Payment of claims is based on active membership on the date of service. Since you were not on an active dental plan, the services remain your financial responsibility. Therefore, we decided that the Plan does not have to pay for the dental services provided on January 13, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial hospital care provided on August 9, 2019.You asked the Plan to pay forthe physician services. You say that the claim was initial paid. You also say that the payment was recouped due to an overpayment.The Plan denied your request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.Medicare rules say that Original Medicare, not thePlan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on August 6, 2019. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe initial hospital care provided on August 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 17, 2018 by an out of network (OON) provider.You asked the Plan to pay for the office visit (99213). You say that you would like reconsideration because you were not aware that authorization was needed to see an out-of-network provider.The Plan denied your request. The Plan says your plan does not have out-of-network benefits.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 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 medical services provided on October 17, 2018 by an out of network (OON) provider.Your complaint about receiving misinformation regarding this service is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forbitewing -single radiographic image (D0270), detailed and extensive oral evaluation -problem focused, by report (D0160), intraoral -periapical first radiographic image (D0220) and endodontic therapy, molar tooth (excluding final restoration) (D3330) provided on January 10, 2020.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC 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.After reviewing the factsconcerning to your  case, we proceeded to confirm the Plan's initial decision to denycoverage for the service requested because the amount appealed by you corresponds to the copayment applied for dental services, which is the responsibility of the member. It is confirmed with the medical office that you were directed before the service procedureabout the corresponding copayment charges that apply.Therefore, we decided that the Plan does not have to pay forbitewing -single radiographic image (D0270), detailed and extensive oral evaluation -problem focused, by report (D0160), intraoral -periapical first radiographic image  (D0220) and endodontic therapy, molar tooth (excluding final restoration) (D3330) provided on January 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 2, 2018 to November 28, 2018.

You asked the Plan to pay for the skilled nursing services. You say that this claim should be paid in full because it was submitted on time with all of the documentation. The Plan denied your request. The Plan says they do not see that the enrollee's condition will continue to improve in a sensible and expected period of time. The Plan also says that they do not see that the enrollee will benefit from additional skilled therapy 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.
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 pay for the skilled nursing 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from November 2, 2018 to November 28, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from June 8, 2019 to June 25, 2019.You asked the Plan to pay for the skilled nursing services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services performed exceeds what was approved on the authorization.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 pay for the skilled nursing 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 skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from June 8, 2019 to June 25, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost for the ophthalmic biometry provided on March 26, 2019 and April 4, 2019.We decided that the Plan does not have to waive the cost share for the remaining services.You asked the Plan to waive the cost sharethe outpatient services. You say that it is your understanding that your $150 deductible would cover all necessary medical procedures.The Plan denied your request. The Plan says the cost share applied correctly.We decided that the Planhas reduce the cost for the ophthalmic biometry provided on March 26, 2019 and April 4, 2019.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 4% of the cost for in-network, Medicare-covered diagnostic procedures or tests. The ophthalmic biometryis considered a diagnostic test. Therefore, the plan has to reduce the cost from a $25 copayment to 4% coinsurance.Date of ServiceServiceAllowed AmountCoinsuranceMember LiabilityMarch 26, 2019Ophthalmic Biometry$72.554%$2.90April 4, 2019Ophthalmic Biometry$32.514%$1.30TOTAL:$4.20We also decided that the Plandoes not havewaive the cost for the remaining services.Date of ServiceServiceProviderAllowed AmountStandard Cost ShareMember LiabilityApril 2, 2019Eye ExamPhysician$91.55$25$25April 3, 2019Cataract RemovalPhysician$675.61$25$25April 3, 2019Cataract RemovalFacility$973$150 deductible$150April 3, 2019Cataract RemovalFacility$8234%$32.92April 3, 2019AnesthesiaFacility$149.764%$5.99April 10, 2019Cataract RemovalPhysician$675.61$25$25April 10, 2019Cataract RemovalFacility$9734%$38.92April 10, 2019AnesthesiaFacility$152.244%$6.09TOTAL:$308.92This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing isa 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 for the remaining services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to payforhome health infusion services provided to the enrollee on September 10, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the denied code is a bundled service, and there are no RVUs and no payment amounts for this service.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 the denied codes is:HCPCS A4220:Refill kit for implantable infusion pumpHCPCS J3490:Unclassified drugsCPT 62370:Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status)HCPCS J3010:Injection, fentanyl citrate, 0.1 mg 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 not coded correctly. Our physician reviewer found according to the NCCI edits, HCPCS code A4220 should note be billed alongside CPT code 62370, as CPT code 62370 already includes a refill kit. Billing both CPT code 62370 and HCPCS code A4220 is effectively double billing for the refill kit. The separate billing of HCPCS code A4220 is not supported.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 not been met.Therefore, we decided that the Plan does not have to pay forhome health infusion services provided to the enrollee on September 10, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 3, 2019 by an out of network (OON) provider.You asked the Plan to pay for echocardiogram. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior approval 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 has network providers available who can provide 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 medical services provided on January 3, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.You asked the Plan to pre-approve Retacrit. You say that this is medically necessary.The Plan denied your request. The Plan says payment for this drug will be bundled into payment to the dialysis agency.The Plan must follow Medicare rules. Medicare rules say that all drugs and biologicals used for the treatment of ESRD are included in the ESRD PPS and are not separately paid as of January 1, 2011. Erythropoiesis stimulating agents (ESAs)furnished to Medicare ESRD patients are always considered to be renal dialysis services and included in the ESRD PPS.We looked at the file and Medicare rules.The requested drug is considered to be renal dialysis services and included in the ESRD PPS.Separate payment for this drug cannot be pre-approved by the Plan. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met.Therefore, we decided that the Plan does not have to pre-approveRetacrit.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided to the enrollee from January 1, 2019 through January 24, 2019.You asked the Plan to waive the copayment for SNF care. You say that you are appealing the member's cost-share responsibility for the services the member received.The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). For dates of service January 01 through January 24, 2019, the provider billed the Plan $10, 442.00 with the Plan paying $6762.00. The Medicare allowable is $10,442.00 and the member was assessed their copayment of $3,680 to member responsibility for 23 days of their plan benefit. Plan benefit $160 X 23 days = $3,680.00. 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 copayment forSNF care provided to the enrollee from January 1, 2019 through January 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on May 23, 2019 by an out of network (OON) provider.You asked the Plan to pay for outpatient lab work. You say that you would like this claim reprocessed and approved for payment.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 has network providers available who can provide 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 outpatient lab work provided on May 23, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora shingles vaccine (90471 and 90736) provided on January 16, 2020.You asked the Plan to pay forthe shingles vaccine. You say that you would like reconsideration because you were not aware that you had to get your vaccine at the pharmacy.The Plan denied your request. The Plan says your evidence of coverage does not provide benefits for this service.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine.Therefore, we decided that the Plan does not have to pay fora shingles vaccine (90471 and 90736) provided on January 16, 2020.Benefits for the shingles vaccinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services provided on September 9, 2019 by an out of network (OON) provider.You asked the Plan to pay for the radiology services. You say that provider ordered the radiology services for the enrollee based on medical necessity and appropriateness.The Plan denied your request. The Plan says Physicians and referring provider are non-contracted providers. The Plan says that authorization was not obtained for the out of network services in dispute.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 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 radiology services provided on September 9, 2019 by an out of network (OON) provider.