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

We decided that the Plan does not have to pay for the anesthesia services (64999) provided on November 24,
2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
billed incorrectly.
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 code 64999 is not supported in the medical record. Specifically, it is inappropriate for an
anesthesia practitioner to bill CPT code 64999. Anesthesia services provided by an anesthesia practitioner must
be billed with CPT codes 00100-01999. 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 the
anesthesia services (64999) provided on November 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forphysical therapy services provided on February 20, 2020 to February 27, 2020 by an out of network provider.You asked the Plan to pay forthe physical therapy services. You say that the Plan told your specialists that a Prior Authorization would not be needed.The Plan denied your request. The Plan says you did not request 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forphysical therapy services provided on February 20, 2020 to February 27, 2020 by an out of network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 10, 2020, by an out-ofnetwork
provider.
You asked the Plan to pay for the office visit. You say that an office visit does not require authorization. The
Plan denied your request. The Plan says you did not request 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 had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service
at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that
the Plan does not have to pay for the office visit provided on June 10, 2020, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vertical bitewings, 7 to 8 images, (D0277) provided on October 13, 2020.

You asked the Plan to pay for the dental service. You say that according to your benefits, bitewing x-rays are covered with a 100% or 50% coinsurance. You also say that your benefits say that 1 per calendar year (D0270, D0272, D0273, and D0274 share frequency) is covered. The Plan denied your request. The Plan says vertical bitewings, 7 to 8 images, 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 vertical bitewings, 7 to 8 images, (D0277) provided on October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the refractive state determination provided by an out-of-network provider on April 18, 2018.
You asked the Plan to pay for the refractive state determination. You say that the Plan said there were no deductibles before December. You say that you want to know why you have to pay these bills. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 refractive state determination provided by an out-of-network provider on April 18, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) provided on December 17, 2020.

You asked the Plan to pay for the bone replacement graft. You say that you are unhappy because the portal does not describe why the service is not covered. The Plan denied your request. The Plan says this service is not covered.

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 bone replacement graft for ridge preservation (D7953) provided on December 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on January 14, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on January 14, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical service provided on October 10, 2020.
You asked the Plan to pay for the medical service (99053). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no fee schedule for code 99053.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99053 is Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility. We find that CPT code 99053 is not separately payable. Specifically, 99503 has a status code of B. Payment for this service is bundled with the primary service. Based on this information, we decided that Medicare rules for coverage of the medical service (99053) have not been met. Therefore, we decided that the Plan does not have to pay for the medical service provided on October 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on
November 17, 2020.

You asked the Plan to waive the copayment for these services. You say that the copayment should be waived.
The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275
copayment for surgical services at an in-network ambulatory surgical center.

Review of the file shows that you had a diagnostic colonoscopy on November 17, 2020. The colonoscopy was
diagnostic and not screening in nature due to a personal history of colon polyps. You have been asked to pay a
$275 copayment for these services. These services fall within the surgical services at an in-network ambulatory
surgical center benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgical
services rendered on November 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the complete maxillary denture or pay for the complete mandibular denture provided on November 20, 2020.

You asked the Plan to pay more for the complete maxillary denture and to pay for the complete mandibular denture. You say that you were advised that you had an $800 dental allowance at the time of this service. The Plan denied your request. The Plan says your accrued quarterly benefits of $800 was fully exhausted.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $200.00 allowance for comprehensive dental services every quarter. The contract says that after your quarterly benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the quarterly maximum benefit while processing this claim for the November 20, 2020 date of service and your quarterly maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the complete maxillary denture or pay for the complete mandibular denture provided on November 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (95004) provided on September 23, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95004 is "Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests". We asked our coding 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 use of CPT code 95004 is not supported by the records provided. Our coding reviewer found that the procedure report does not include enough documentation to confirm all criteria for CPT 95004 has been performed. The report documents arm, however, no information documented to support (scratch, puncture, prick), as well as documentation of allergenic extracts and report. Therefore, CPT 95004 cannot be confirmed. We looked at this coder'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 the services (95004) provided on September 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom fabricated abutments (D6057) with precision attachments (D5862).
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says these services are not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. The Plan covers only those dental services for which the dental codes are listed in the Evidence of Coverage. Any code not listed is not covered. Dental codes D6057 and D5862 are not listed, and therefore are not covered. Therefore, we decided that the Plan does not have to pre-approve custom fabricated abutments (D6057) with precision attachments (D5862).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation, and to pay for the bitewing
x-rays and prophylaxis provided on December 10, 2020.
You asked the Plan to pay more for the periodic oral evaluation, or pay for the bitewing x-rays and prophylaxis.
You say that your appointment date was changed, and you would like these services to be covered under your
2021 benefits. The Plan denied your request. The Plan says you have exhausted your yearly dental allowance of
$255.
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 Plan offers a $255 allowance every
year for Non-Medicare covered preventive and comprehensive dental services combined. The contract says that
you are responsible for any amount above the dental coverage limit. The record shows that you met the annual
maximum benefit while processing this claim for the December 10, 2020, date of service and your annual
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the
periodic oral evaluation, and to pay for the bitewing x-rays and prophylaxis provided on December 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for automatic external defibrillator (CPT code K0606 RR-KF-KH-KX) provided to the enrollee on October 25, 2020.

You asked the Plan to pay for the DME. You say that each of the claims at issue meets Medicare coverage criteria. The Plan denied your request. The Plan says the enrollee was in the hospital from October 18, 2020, through November 2, 2020.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. 

Records show that the DME was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for automatic external defibrillator (CPT code K0606 RR-KF-KH-KX) provided to the enrollee on October 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ipilimumab and Nivolumab.
You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says the drug combination is not supported for the enrollee's cancer.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 requested drugs. Our physician reviewer found that the enrollee has endometrial cancer. The requested use of the drug combination is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Single agent Pembrolizumb is the standard of care in MSI-H endometrial cancer. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 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 requested drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Ipilimumab and Nivolumab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of
intraoral x-rays provided on November 3, 2020.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You
say that you would like these services to be coded correctly and covered. The Plan denied your request. The
Plan says benefits for these services have been satisfied and the frequency limitations have 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, comprehensive oral evaluation is
limited to one procedure every three years and panoramic or diagnostic x-rays are limited to one procedure
every five years. The record shows that you received a comprehensive oral evaluation and complete series of
intraoral x-rays on February 7, 2019, and your comprehensive oral evaluation and panoramic or diagnostic xrays
benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation and complete series of intraoral x-rays provided on November 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3330) provided on November 23, 2020.

You asked the Plan to pay for the dental service. You say that your claim was denied for lack of coverage. You say that you would like to terminate your dental coverage. You say that it is not worth it to pay $446 each per year for a simple teeth cleaning. The Plan denied your request. The Plan says root canal is not listed as a covered service. The Plan says that you were not enrolled in the Dental Rider on the date of service. The Plan also says that you were disenrolled from the Dental Rider as on September 30, 2020, due to non-payment of plan premiums. The Plan also says that.

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 root canal (D3330) provided on November 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (HCPCS G0156) provided to the enrollee on September 28, 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 Current Procedural Terminology (CPT) code G0156 remains not supported.
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 HCPCS code G0156 is "Services of home health/hospice aide in home health or hospice settings." We asked our coding 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 supported by the medical records. Our coding reviewer found the documentation submitted did not include home health services for the dates billed, and therefore, cannot be verified as performed. We looked at this coder'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 home health services (HCPCS G0156) provided to the enrollee on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary visit provided on November 3, 2020 by an out of network provider.

You asked the Plan to pay for domiciliary visit (99326). You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request 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 had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for domiciliary visit provided on November 3, 2020 by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pre-filled Prolia Sol syringes for use at home.
You asked the Plan to pre-approve self-administered drug. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve pre-filled Prolia Sol syringes for use at home.
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.