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

We decided that the Plan does not have to waive the deductible for the psychiatric evaluation provided on May 23, 2019.
You asked the Plan to waive the deductible for the psychiatric evaluation. You say that you would like to be reimbursed and charged the in-network rate. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $1,000 deductible that applies towards out-of-network psychiatric evaluations. The psychiatric evaluation you asked the Plan to waive the deductible for falls within the "Outpatient mental health care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible that applies towards out-of-network psychiatric evaluations. The allowed amount for the psychiatric evaluation is $150. Therefore, $150 is the amount that is applied to your deductible.
This cost sharing is a contractual obligation that had not been met at the time the psychiatric evaluation was received on May 23, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the psychiatric evaluation provided on May 23, 2019.
Your complaint about the Plan's lack of providers and performance about the appeal 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 pre-approve pontics for tooth #'s 13 and 14, retainer crowns for tooth #'s 13, 15, 29, and 31, and crowns for tooth #'s 7, 8, 9, and 10.
You asked the Plan to pre-approve the pontics, retainer crowns, and crowns. You say that you have decay and discoloration on tooth #'s 8 and 9, and want to add crowns to tooth #'s 7 and 10 to restore the increasing space between your teeth. You also say that you would like a bridge to restore your chewing ability. The Plan denied your request. The Plan says these services are not medically necessary.
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 the pontics, retainer crowns, and crowns when the services are medically necessary and reasonable. 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 pontics, retainer crowns, and crowns. Our reviewer says that the services are not medically necessary. Our physician reviewer found the pontics are not reasonable and medically necessary for tooth #'s 13 and 14. Our reviewer found that the retainer crowns for tooth #'s 13 and 15 are not necessary as these teeth are not present in the dental arch. The retainer crowns for tooth #'s 31 and 29 may be reasonable as an alternative treatment plan for a fixed bridge, however they are not necessary. Our physician reviewer also found that the crowns on 7, 8, 9, and 10 are not medically reasonable and necessary because tooth #'s 7 and 10 have no existing restorations and do not appear to have any significant decay or loss of structure, and tooth #'s 8 and 9 have existing crowns that do not appear to have any structural issues or recurrent decay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the full amount for the periodontal maintenance (D4910) provided on December 10, 2019. You asked the Plan to reimburse the full amount for the dental service. You say that you were under the impression that you were covered for 2 cleanings per calendar year. You say that upon arrival, the provider mentioned the cleaning would be different from what you have received in the past. You also say that you did not think to question the type of cleaning. You also say that you assumed it would be covered. The Plan denied your request. The Plan says periodontal maintenance is not 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, periodontal maintenance is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse the full amount for the periodontal maintenance (D4910) provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (99285) and electrocardiogram (93010) provided on November 26, 2019.
You asked the Plan to pay for the emergency department visit and electrocardiogram. You say that you would like reconsideration because this claim has been billed correctly. The Plan denied your request. The Plan says a secondary only diagnosis cannot be used as the primary, first-listed or principal diagnosis for any procedure or service.
The Plan must follow Medicare rules. Medicare rules say that when coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug (T36-T50). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency department visit and electrocardiogram have not been met. Specifically, the diagnosis code billed should not be assigned as principal or first-listed code. The billed diagnosis code should follow an appropriate code for the nature of the adverse effect. Therefore, we decided that the Plan does not have to pay for an emergency department visit (99285) and electrocardiogram (93010) provided on November 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection rendered on October 2, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code J3301 is 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 code J3301 is injection, triamcinolone acetonide, not otherwise specified, 10 mg.We find that CPT code J3301 is not supported in the medical record. Specifically, the documentation does not indicate that an injection of 10 mg of triamcinolone acetonide was administered. 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 injection rendered on October 2, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0120) and periodontal maintenance (D4910) provided on October 10, 2019.
You asked the Plan to pay for the dental services. You say that you are required to have periodontal maintenance every 4 months. You say that anything less will cause more dental issues. You also say that the plan should consider covering 1 additional periodontal cleaning per year. The Plan denied your request. The Plan says oral exams and periodontal maintenance have a frequency limit of 2 procedures per plan year. The Plan also says that the frequency limit has been exceeded for these services.
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 oral exams and periodontal maintenance are covered services, the frequency limit for these services have been exceeded. The record shows that the Plan paid for these services that you received on March 12, 2019 and July 9, 2019. Therefore, we decided that the Plan does not have to pay for the oral evaluation (D0120) and periodontal maintenance (D4910) provided on October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on November 25, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care and the referring provider was 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 has network providers available who can provide 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 these services. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2025) provided on November 11, 2019.
You asked the Plan to pay for the vision service. You say that you assumed you would receive the full reimbursement of $69.95 for the cost of 2 pairs of glasses but only $55.99 was covered. The Plan denied your request. The Plan says this claim was processed 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 $65 copay for standard progressive lenses or $65 copay plus 80% of the retail charge, minus $120 plan allowance for premium progressive lenses. There is a $250 allowance for the purchase of 1 set of frames, or 1 pair of eyeglass lenses or contact lenses instead of eyeglass lenses every 2 calendar years. for Vision care. You have been asked to pay $34.97 for the vision service. The records show that you received the in-store promotional discount, and purchased 2 complete pairs for $69.95. The vision service falls within the Vision care 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 pay for deluxe frames (V2025) provided on November 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 4, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care services provided to the enrollee on December 5, 2019.
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 the plan requires the utilization of in network providers unless the plan pre-approves out of network services in non-emergent situation.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided he Plan does not have to pay for wound care services provided to the enrollee on December 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the 200mg Celecoxib capsules, 325mg Acetaminophen tablets, 100mg Docusate Sodium capsules, Polyethylene Glycol 3350 17 gram, and 500mg Acetaminophen tablets provided on November 25, 2019 and November 26, 2019.
You asked the Plan to pay for the Celecoxib, Acetaminophen, Docusate Sodium, and Polyethylene Glycol. You say that you do not understand why medication that was given to you in the hospital is not covered. The Plan denied your request. The Plan says Part B generally does not pay for self-administered drugs used in the hospital outpatient setting. The Plan also says that if you get self-administered drugs that are not covered by Medicare Part B while in a hospital outpatient setting, the hospital may bill you for the drug.
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 the 200mg Celecoxib capsules, 325mg Acetaminophen tablets, 100mg Docusate Sodium capsules, Polyethylene Glycol 3350 17 gram, and 500mg Acetaminophen tablets provided on November 25, 2019 and November 26, 2019.
Benefits for Celecoxib, Acetaminophen, Docusate Sodium, and Polyethylene Glycol may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the eye exam (92014), eye refraction (92015), and the contact lens fitting (92310) rendered by the out of network (OON) provider on September 12, 2019.
You asked the Plan to issue reimbursement for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 issue reimbursement for the eye exam (92014), eye refraction (92015), and the contact lens fitting (92310) rendered by the out of network (OON) provider on September 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for otolaryngology services (CPT 30140) provided to the enrollee on July 9, 2019.
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 procedure code 30140-50 is not supported by the medical records submitted
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 30140 is "Submucous resection inferior turbinate, partial or complete, any method." We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found there is no evidence that the enrollee's inferior turbinates were resected. Rather, it appears that a bilateral outfracture was performed. Therefore, the billing of CPT 30140 is not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for otolaryngology services (CPT 30140) provided to the enrollee on July 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (G0482) provided on September 10, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services (G0482) provided on September 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on December 13, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the Plan should pay this claim.
The Plan denied your request. The Plan says the documentation submitted did not indicate the provider
discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for
the orthoses. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral
orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbarsacral
orthosis provided on December 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the anti-reflective coating (V2750) purchased on October 22, 2019.
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the lens option purchased by you does not meet criteria for coverage under your contractual policy.
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. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of this service have not been met. Specifically, the lens option purchased by you is not a covered benefit without the purchase of base lenses. Therefore, we decided that the Plan does not have to issue reimbursement for the anti-reflective coating (V2750) purchased on October 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe fillings (D2391) for teeth # 3 and 5 provided on November 11, 2019 by an out of network provider.You asked the Plan to pay for2 additional fillings. You say that you had 4 fillings done to counteract the eroding of your teeth at the gum line. You also say that you needed the fillings to strengthen and protect them from possible fracture as they have become greatly weakened over the years.The Plan denied your request. The Plan says 2 fillings per calendar year are covered. The Plan also says the benefit for fillings has been 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 and fillings are a covered service, only 2 fillings per calendar year are covered. The record shows that the Plan paid for the fillings for teeth # 10 and 11.Therefore, we decided that the Plan does not have to pay forthe fillings (D2391) for teeth # 3 and 5 provided on November 11, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint injection.
You asked the Plan to pre-approve sacroiliac joint injection. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections are only covered if previous
diagnostic or therapeutic SI injections of an anesthetic and/or steroid to block the joint for immediate, and
potentially long lasting, pain relief have not effectively relieved the pain.
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 sacroiliac joint injection. Our reviewer
says that the documentation does not support that the requested sacroiliac joint injection is medically
reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain. The enrollee
underwent bilateral sacroiliac joint injection and achieved 2 days of pain relief. The documentation shows that
the previous block provided meaningful relief for only 2 days. Therefore, the request does not meet the LCD
criteria and is deemed not medically reasonable or 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 sacroiliac joint injection have not been met. Therefore, we decided that the Plan
does not have to pre-approve sacroiliac joint injection.