Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound (76705) provided September
14, 2020.

You asked the Plan to waive the copayment for the ultrasound. You say that the copayment should be waived.
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 $100
copayment for Diagnostic Tests and Procedures.

You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the Diagnostic
Tests and Procedures 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
ultrasound (76705) provided September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on October 1, 2020.
You asked the Plan to pay for the resin-based composite. You say that it is important for heart health to have good oral hygiene. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan 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, 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 the resin-based composite provided on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided September 30, 2020.
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied your request. The Plan says the CPT code billed shares a bundled relationship with another service paid on the same date of 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, we have confirmed that code 71045 has a Column I / Column II relationship with code 36573 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy for a premolar tooth (D3320)
provided on July 6, 2020.
You asked the Plan to pay for the dental service. You say that this service was necessary for your mental, oral
and general well-being which you suffered deeming it as an emergency based on the procedure and the
medications prescribed after. The Plan denied your request. The Plan says endodontic therapy for a premolar
tooth 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 the
endodontic therapy for a premolar tooth (D3320) provided on July 6, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says if an individual's expected rehabilitation potential is insignificant in relation to the extent
and duration of therapy services required to achieve such potential, rehabilitative therapy is not reasonable and
necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 services. Our reviewer says that
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific
and effective therapy your condition.
You have had extensive therapy for your condition, and the documentation does not indicate that your
functional level requires the unique skills of a professional therapist to safely and effectively provide
treatment, or that the services can be safely and effectively performed only by a therapist, or under the
supervision of a therapist. You are competent in a home exercise program. The requested services are not part
of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not
required to establish, design and/or deliver a program to maintain your current condition, or to prevent or slow
further deterioration. 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 pre-approve continued physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on June 30, 2020.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not a covered benefit under your Part B plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on June 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for replacement of lead wires (A4557) for a TENS unit received on September 30, 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 since the unit was purchased in the last 12 months, this is denied.
The Plan must follow Medicare rules. Medicare rules say replacement of lead wires (A4557) more often than every 12 months would rarely be reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found a claim was submitted for extra (replacement) wires. There was no indication within the medical records provided as to why replacement wires were offered/provided. There was no indication that the device was not in working order that would have otherwise necessitated replacement so early on in the "life" of the device. In as much the replacement wires (under review) cannot be said to be reasonable and necessary. 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 for replacement of lead wires (A4557) for a TENS unit received on September 30, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90834) provided October
2, 2020.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically
necessary. The Plan denied your request. The Plan says the provider is not enrolled and is not eligible for
Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare
program.
We looked at the file and Medicare rules. The rendering provider is not enrolled in the Medicare program and
is a type of provider (Marriage & Family Therapist) that is not eligible for enrollment. Based on this
information, we decided that Medicare rules for coverage of the outpatient mental health services have not been
met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90834)
provided October 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the member it too unstable from a respiratory perspective at
this time to consider being transitioned out of the acute facility to any alternative level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the
LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Eliquis 5 mg tablet.
You asked the Plan to pay for Eliquis. You say that this request is medically necessary. The Plan denied your request. The Plan says this drug is not covered for your condition by Medicare Part B.
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 Eliquis 5 mg tablet.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (93010, 99292, 99291) provided
April 1, 2019.
You asked the Plan to pay for the emergency room services. You say that the services were medically
necessary. The Plan denied your request. The Plan says the claim was not filed timely.
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 emergency room services was not filed until July 22, 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 emergency room services (93010, 99292, 99291) provided April
1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray,
prophylaxis, resin-based composites, and bitewing x-rays provided from August 17, 2020, to October 5, 2020
by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, first intraoral periapical x-ray, prophylaxis, resinbased
composites, and bitewing x-rays. You say that you would like to be reimbursed for these services. The
Plan denied your request. The Plan says these services were performed by an OON provider, and you are
responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for
the services. The Plan also says that your benefits for the resin-based composites had been satisfied and the
frequency limitation had been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, composite restorations (fillings) are
limited to one procedure per calendar year. The record shows that you received a resin-based composite on
September 17, 2020 that was covered by the Plan, and your composite restorations benefit had been exhausted.
You are also responsible for the difference between the billed amount and allowed amount when services are
received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, first
intraoral periapical x-ray, prophylaxis, resin-based composites, and bitewing x-rays provided from August 17,
2020, to October 5, 2020 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.
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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device is experimental. More research is needed to show safety and efficacy. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete lower denture (D5120) provided on September 24, 2020.
You asked the Plan to pay for the dental items. You say that you did not receive the previous dentures. You say that they are still at the office. You say that they did not fit your mouth at all. You also say that the wrong dental office was paid. The Plan denied your request. The Plan says 1 set of upper and/or lower dentures are covered every 5 years. The Plan says that the frequency limit has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 complete upper and/or lower denture every 5 years has been exceeded. The record shows that the Plan paid for a complete set of dentures that were provided on June 8, 2020. The record shows that you consented to the denture work and after multiple appointments for the initial impression, fitting for the wax rim mold, and then a wax rim try- in for any final adjustments, the lab completed the order and you never returned for delivery of the finished dentures that are at their office. Therefore, we decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete lower denture (D5120) provided on September 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray provided on July 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an x-ray. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an x-ray provided on July 8, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90791) provided on May
1, 2019.
You asked the Plan to pay for a psychiatric diagnostic evaluation. You say that you did not receive the
necessary information to file this claim timely. The Plan denied your request. The Plan says claims must be
filed within a year of the date of service.
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 a psychiatric diagnostic evaluation was not filed until August 27, 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 a psychiatric diagnostic evaluation (90791)
provided on May 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 9.
You asked the Plan to pre-approve the dental service. You say that the core build up is necessary. The Plan denied your request. The Plan says core build up 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 pre-approve core build up (D2950) for tooth # 9.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on September 18,
2020.

You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says
non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
diagnostic radiology services. 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 diagnostic radiology services provided on
September 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction you had on September 24, 2020.

You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not cover eye refractions. 

The service you asked the Plan to pay for is an eye refraction. This is not covered under Medicare or your plan. Therefore, we decided that the Plan does not have to pay for the eye refraction you had on September 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray provided on August 26, 2020 by an out of network (OON) provider.

You asked the Plan to pay for an x-ray. You say that you would like this claim reprocessed and paid. You say that you thought you were in-network. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the rendering provider is out-of-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an x-ray provided on August 26, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020) purchased on August 29, 2020.

You asked the Plan to pay for eyeglass frames. You say that the non-contracted provider was the closest place
selling frames. The Plan denied your request. The Plan says rules for payment have not been met.

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. The Plan covers these services when obtained from a Plan-contracted provider.

We looked at the file and the Plan's rules. You purchased frames from a non-contracted provider. Based on this
information, we decided that the Plan's rules for coverage of eyeglass frames have not been met. Therefore, we
decided that the Plan does not have to pay for eyeglass frames (V2020) purchased on August 29, 2020.