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

We decided that the Plan does not have to pre-approve a maxillary partial denture - resin base (including, retentive/clasping materials, rests, and teeth) (D5211).
You asked the Plan to pre-approve an upper partial denture. You say that you would like the partial denture covered. The Plan denied your request. The Plan says the partial denture was covered less than 60 months ago and is therefore not yet eligible for coverage.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maxillary partial denture once every 5 years. We looked at the file and Medicare rules. The Plan provided documentation showing that an upper partial denture was previously covered on October 23, 2017. Based on this information, we determined that you are not yet eligible for coverage of a new upper partial denture. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture - resin base (including, retentive/clasping materials, rests, and teeth) (D5211).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a
participating provider on January 11, 2021.
You asked the Plan to waive the copayment for an outpatient surgery. You say that the doctor performed the
initial procedure incorrectly. You say that you do not agree with 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 $264
copayment for outpatient surgery/in-network/in-network/outpatient hospital.
You have been asked to pay a $264 copayment for an outpatient surgery. The correct copayment has been
applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/innetwork/
in-network/outpatient hospital 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 outpatient surgery provided by a participating provider on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided by a participating
provider on March 30, 2021.
You asked the Plan to waive the deductible for an office visit. You say that you do not agree with this
deductible. The Plan denied your request. The Plan says the correct deductible amount has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $203 deductible for physician/practitioner services.
The item or service you asked the Plan to waive the deductible for falls within the benefit category
physician/practitioner services. The Plan has followed Medicare rules by clearly disclosing in the contract that
there is a $203 deductible for physician/practitioner services. The total amount you are being asked to pay is
$138.80. This cost sharing is a contractual obligation that had not been met at the time an office visit was
received on March 30, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an
office visit provided by a participating provider on March 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (13101, 13102) provided on November 3, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services
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 13101 is "Repair, complex, trunk; 2.6 cm to 7.5 cm."

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 use
of code 13101 is not supported by the records provided. Our physician reviewer found that for wound repair to
be eligible for payment at the complex level, the operative report should include documentation of the layered
closure, the layers involved, the number of sutures used in each layer, the total length of the repair in
centimeters and any debridement or reconfiguration performed. The documentation in the operative note is
insufficient to support the use of CPT 13101.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of code 13101 have not been met.

Additionally, CPT code 13102 is an add-on code. As the primary procedure code is not covered in this case, the
add-on code is also not payable. Therefore, we decided that the Plan does not have to pay for the services
(13101, 13102) provided on November 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the DXA scan (77080 & 76499) provided on January 21, 2021.
You asked the Plan to pay for the DXA scan (77080 & 76499). You say that the DXA scan (77080 & 76499) provided on January 21, 2021 was medically necessary. The Plan denied your request. The Plan says the enrollee did not meet criteria for the DXA scan (77080 & 76499) provided on January 21, 2021.
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 pay for the DXA scan (77080 & 76499). Our reviewer says that the enrollee did not meet criteria for the DXA scan (77080 & 76499) provided on January 21, 2021. Our physician reviewer found the review has determined that the enrollee did not meet the above Benefit Policy Manual criteria for the DXA scan provided on January 21, 2021. The DXA scan provided on January 21, 2021 was not medically reasonable or necessary for the enrollee in this case. 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 DXA scan (77080 & 76499) have not been met. Therefore, we decided that the Plan does not have to pay for the DXA scan (77080 & 76499) provided on January 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided on October 31, 2020.

You asked the Plan to pay for the lumbar sacral orthosis. You say that the provided lumbar sacral orthosis was medically necessary. The Plan denied your request. The Plan says the provided lumbar sacral orthosis was not medically necessary.

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 pay for the lumbar sacral orthosis. Our reviewer says that the provided lumbar sacral orthosis was not medically necessary. Our physician reviewer found the enrollee's chief complaint was chronic pain located in the lower back. The available documentation in the case file does not support that the requested lumbar-sacral orthosis (LSO) was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back. 

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 lumbar sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis provided on October 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection provided on March 12, 2021 by an out of network provider.

You asked the Plan to pay for therapeutic, prophylactic, or diagnostic injection (96372), and Injection, testosterone cypionate, 1 mg (J1071). You say that the Plan should pay this claim. The Plan denied your request. The Plan says prior authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan 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 the injection provided on March 12, 2021 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for optometry services provided on October 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for optometry services. You say that these services were provided in an assisted living facility. You say that the member did not have a choice with who they saw. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
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 optometry services provided on October 23, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve weight loss surgery for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the enrollee has proven that she has made attempts
at exercise and dietary efforts despite her limitations. The Plan denied your request. The Plan says the BMI
requirements are not met.

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 surgery. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee's BMI is reported as 35 mg/m2, and therefore does not meet the criteria in this case.

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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve weight loss surgery for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the synthetic sheepskin pad (E0188) and the continuous passive motion exercise device (E0935) provided from November 13, 2020, through
November 30, 2020.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the durable medical equipment provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for durable medical equipment rendered by an in-network provider.
You have been asked to pay $92.95 ($464.76 x 20% coinsurance) for the durable medical equipment provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the synthetic sheepskin pad (E0188) and the continuous passive motion exercise device (E0935) provided from November 13, 2020, through November 30, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport provided to the enrollee on January 5, 2021.
You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice election at the time of transport, this claim should be submitted to Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for ambulance transport provided to the enrollee on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) and a drug test (80307) provided on July 7, 2020, by an out of network (OON) provider.
You asked the Plan to pay for an office visit and a drug test. You say that you would like the claims reviewed. The Plan denied your request. The Plan says services were provided by an out-of-network provider without 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 office visit (99213) and a drug test (80307) provided on July 7, 2020, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered from November 18, 2020 to December 15, 2020.
You asked the Plan to pay for these services. You say that there is no valid physician order. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered from November 18, 2020 to December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological services: medical examination and evaluation (92014) and determination of refractive state (92015) provided December 10, 2020.

You asked the Plan to pay for the eye exam and refraction. You say that your services should be covered just like your husband's were covered. The Plan denied your request. The Plan says these services are not covered under your plan.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. 

The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for the ophthalmological services: medical examination and evaluation (92014) and determination of refractive state (92015) provided December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided by an out-of-network provider on January 14, 2021.
You asked the Plan to pay for the physician services. You say that the treatment received was medically necessary and the medical records justify the reason for the member stay. You say that payment should be granted. The Plan denied your request. The Plan says members must receive care from a network provider.
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 the physician services provided by an out-ofnetwork
provider on January 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fillings (D2332 x 3) and the crown (D2751) provided from January 19, 2021, to February 9, 2021.

You asked the Plan to pay for the dental services. You say that your dental benefits were reduced as of December 31, 2020 without any notice. You also say that the dental work was initiated during your coverage period. The Plan denied your request. The Plan says the fillings and the crown are not listed as covered services. The Plan also says that the Annual Notice of Changes (ANOC) for 2021 shows that the optional supplemental dental coverage is not available for 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, the fillings and crown are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the fillings (D2332 x 3) and the crown (D2751) provided from January 19, 2021, to February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office or other outpatient visit (99214) and hospital
outpatient visit (G0463) provided on March 15, 2021, by an OON provider.

You asked the Plan to pay for the office or other outpatient visit and hospital outpatient visit. You say that you
were not aware this provider would be considered OON. The Plan denied your request. The Plan says prior
authorization was not obtained for these services rendered by an OON provider.

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 the office or other outpatient visit (99214) and
hospital outpatient visit (G0463) provided on March 15, 2021, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 13, 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 October 13, 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 October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 25, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that tests that include more than 5 viral pathogens are non-covered. We looked at the file and Medicare rules. The testing at issue includes more than 5 viral pathogens and is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 25, 2020.