Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hyperbaric oxygen services provided by a participating provider on August 24, 2020, to October 21, 2020.
You asked the Plan to waive the copayment for outpatient hospital services. You say that you were never informed that you would have this copayment. The Plan denied your request. The Plan says the correct copayment 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 $40 copayment for outpatient hospital services/services rendered by a specialist. You have been asked to pay a $40 copayment for each outpatient hospital services. The total amount you are being asked to pay is $960 ($40 x 24 visits = $960). The correct has been applied to the services that were
provided. Outpatient hospital services fall within the outpatient hospital services/services rendered by a specialist 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 hyperbaric oxygen services provided by a participating provider on August 24, 2020, to October 21, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from November 27, 2020 to December 4, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. SNF services billed on Type of Bill 21X must be billed with a Patient Driven Payment Model (PDPM) revenue code. We looked at the file and Medicare rules. The file shows that the claim was not billed with the appropriate PDPM revenue code. 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 pay for the skilled nursing facility (SNF) services rendered from November 27, 2020 to December 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 30, 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 explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, 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 laboratory services rendered on December 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81240, 81241, 81328, 81335, 81408, 81230, 81231, 81232, 81283, and 81350 provided on September 1, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 81240, 81241, 81328, 81335, 81408, 81230, 81231, 81232, 81283, and 81350 are not supported in the medical record. Specifically, if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not
have to pay for the laboratory services coded 81240, 81241, 81328, 81335, 81408, 81230, 81231, 81232, 81283, and 81350 provided on September 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses provided on November 9, 2020.
You asked the Plan to pay for the knee orthoses (L1971). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no proof of delivery and the enrollee stated she did not receive the items billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. There is no invoice or proof of delivery document in the file. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the knee orthoses provided on November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on February 21, 2020.
You asked the Plan to pay for the office visit. You say that you were unable to get authorization before the service was done due to the short time period. You say that the medical records prove the service was medically necessary, and the claim should be considered for payment. The Plan denied your request. The Plan says prior authorization was required but 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 office visit provided by an out-of-network provider on February 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on March 23, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service exceeds the maximum allowed per period.
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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on March 4, 2021 and your problem focused limited oral evaluation
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for duplex scan of extremity veins (93971) outpatient office visit (99204) additional supplies and clinical staff time to perform safety protocols (99072) fall risk assessment (3288F) provided on January 11, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient visit. You say that this enrollee was referred to you for an urgent appointment. This was an urgent matter, and you didn't have time to get an authorization. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 duplex scan of extremity veins (93971) outpatient office visit (99204) additional supplies and clinical staff time to perform safety protocols (99072) fall risk assessment (3288F) provided on January 11, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on February 25, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on May 25, 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) provided on February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial upper denture (D5213), and the partial lower denture (D5214) provided on October 1, 2020.
You asked the Plan to pay for the partial dentures. You say that you were told that the provider accepted your plan. You say that you were not aware that the provider was out of network. You say that you are on a fixed income. You also say that you were told that Medicare provides $1,000 towards dentures. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services performed out of network are not covered. The Plan also says that there is no record of receiving any calls from you or provider's office until January 19, 2021.
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 partial dentures are a covered benefit, dental services performed out of network are not covered. Therefore, we decided that the Plan does not have to pay for the partial upper denture (D5213), and the partial lower denture (D5214) provided on October 1, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Home Health Aide 24 hours a day, 7 days per week.
You asked the Plan to pre-approve a home health aide. You say that you cannot put the enrollee in a nursing home. You say that the enrollee has a strong anxiety disorder. You say that you cannot put the enrollee in a nursing home because of Covid-19 too. You say that you the enrollee is running out of money and needs the support of her insurance. You also say that the enrollee is completely dependent on others to care for her. The Plan denied your request. The Plan says the enrollee does not require skilled services.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 a home health aide. Our reviewer says that a home health aide is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has documented skilled nursing needs. Therefore, the reviewer found that the requested home health aide is not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home health aide have not been met. Therefore, we decided that the Plan does not have to pre-approve a Home Health Aide 24 hours a day, 7 days per week.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99232) and a postoperative visit (99232) provided from August 8, 2020 to August 19, 2020.
You asked the Plan to pay for hospital care and a postoperative visit. You say that these services are supported by the records. The Plan denied your request. The Plan says these services are part of a global surgery package.
The Plan must follow Medicare rules. Medicare rules say that payment for visits during the postoperative period of a surgery that are related to recovery from the surgery are included in the Medicare approved amount for the surgery. We looked at the file and Medicare rules. The record shows that an amputation (27590) was performed on the enrollee on June 12, 2020. The postoperative period for this procedure is 90 days, meaning the services at issue are included in the global surgical package and are not separately payable. Based on this information, we decided that Medicare rules for coverage of hospital care and a postoperative visit have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99232) and a postoperative visit (99232) provided from August 8, 2020 to August 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the intraoral - complete series of radiographic images (D0210), the panoramic radiographic image (D0330), and the 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350 x4) received January 20, 2021.
You asked the Plan to pay for the dental services (D0210, D0330, D0150, D0350). You say that you were told by the provider that you would not be charged a copayment for the visit. The Plan denied your request. The Plan says the services received are either not covered under your supplemental benefit or are restricted by frequency limitations.
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 or are in excess of what is allowed under this benefit. The Plan contract allows one comprehensive oral evaluation every three years. In addition, the Plan contract limits complete series and panoramic radiographic images to one procedure every five years. The Plan has submitted evidence that coverage was provided for these services on June 5, 2019. These benefits were exhausted on January 20, 2021. There is no coverage for 2D oral/facial photographic images. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the intraoral - complete series of radiographic images (D0210), the panoramic radiographic image (D0330), and the 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350 x4) received January 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 28, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment 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 28, 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 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210) provided on December 18, 2020.
You asked the Plan to pay for an intraoral complete series of radiographic images. You say that you did not want the service at issue done. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every year.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an intraoral complete series of radiographic images have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on November 16, 2020. Therefore, we
decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210) provided on December 18, 2020.
Your complaint about the provider performing a service you did not want 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 for the porcelain pontic (D6242) and retainer crowns (D6752) provided on February 3, 2021.
You asked the Plan to pay for the dental bridgework. You say that your dentist told you that this work needed to be done, so you waited until 2021 and purchased additional dental coverage and went ahead with the work. Now you are finding that these services are not covered. You feel the fixed bridgework is most beneficial to you due to other health conditions, and you believed that the retainer crowns would be covered because the Plan covers crowns. The Plan denied your request. The Plan says these services are not covered by your dental benefit under any conditions. Please note that a restorative crown is not the same as a retainer crown for a fixed bridge.
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 porcelain pontic (D6242) and retainer crowns (D6752) provided on February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation and extractions to be provided by an oral surgeon.
You asked the Plan to pre-approve the consultation and extractions. You say that you have a cough, an infection and you are in pain. You say that you were only prescribed antibiotics. The Plan denied your request. The Plan says your contract only provides coverage for dental services when they are performed by a participating general dentist.
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 consultation and extractions to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on February 18, 2021.
You asked the Plan to pay for the occlusal guard. You say that you were not aware that the occlusal guard would not be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal guard (D9944) provided on February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Chiropractic office visit, therapeutic activities and manipulative treatments provided on September 2, 2020, September 8, 2020, and September 16, 2020.
You asked the Plan to reimburse you for the Chiropractic office visit (99201), therapeutic activities (97530) or manipulative treatments (98943). You say that you had to pay out of pocket and would like to be reimbursed. The Plan denied your request. The Plan says the office visit, therapeutic activities and manipulative treatments are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to reimburse you for the Chiropractic office visit, therapeutic activities and manipulative treatments provided on September 2, 2020, September 8, 2020, and September 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on October 19, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that your lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 lab work provided on October 19, 2020 by an out of network (OON) provider.