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

We decided that the Plan does not have to pay for medical supplies provided on March 4, 2021 by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for medical supplies. You say that the enrollee had an approved admission and as
such is entitled to received surgical dressings as a covered benefit. The Plan denied your request. The Plan says
the denial of payment for these supplies is correct, because this provider is out-of-network with the Plan and
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 medical supplies provided on March 4, 2021 by an
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the maxillofacial area (70486) provided on April 12, 2021.
You asked the Plan to waive the copayment for a CT scan of the maxillofacial area. You say that the service at issue should be a covered service. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for advanced imaging services performed at an outpatient hospital. You have been asked to pay a $107.75 copayment for a CT scan of the maxillofacial area. A CT scan of the
maxillofacial area falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay less than or equal to the full 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 a CT scan of the maxillofacial area (70486) provided on April 12, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for hemoglobin glycosylated (A1C) testing provided on May 28, 2020.
You asked the Plan to pay for lab test. You say that the diagnoses listed should be enough to show the medical
necessity reasoning for this testing. The Plan denied your request. The Plan says that the denial of payment for
this testing is correct, because predictive screening testing is not a Medicare benefit.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan denied payment for this testing because they claim this testing was
screening in nature. However, this testing was not ordered for screening purposes. The Plan did not provide any
other rationale to support their denial, and even stated that their denial was not based on a medical necessity
decision. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or
justified according to Medicare rules. Therefore, we decided that the Plan has to pay for hemoglobin
glycosylated (A1C) testing provided on May 28, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) received March
23, 2021.
You asked the Plan to pay for the panoramic radiographic image. You say that the Plan should pay for the
requested service. The Plan denied your request. The Plan says the requested service is not covered under your
supplemental 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 items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
panoramic radiographic image (D0330) received March 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology services coded 88112 provided on April 15, 2021.
You asked the Plan to pay for the cytopathology services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 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. In this case, we have confirmed that code 88112 for the cytopathology services has a bundled relationship with code 88188 and cannot be paid as billed. Code 88188 was billed by a provider of the same specialty for the same date of service. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the cytopathology services coded 88112 provided on April 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services rendered by the out-of-network (OON) provider on December 7, 2020.
You asked the Plan to pay 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 rendered 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 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 medical services rendered by the out-of-network (OON) provider on December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) provided on March 24, 2021.
You asked the Plan to pay for the extraction (D7140). You say that you had an extraction due to severe pain which was an emergency. You say that you already paid $118 up front and insurance should cover the balance of the bill. The Plan denied your request. The Plan says extractions are only covered with the additional purchase of the Platinum Dental Rider.
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 extraction (D7140) provided on March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), an intraoral periapical
radiographic image (D0220), and an extraction (D7140) provided on April 12, 2021.
You asked the Plan to pay for a limited oral evaluation, an intraoral periapical radiographic image, and an
extraction. You say that you do not understand why these services are not covered. The Plan denied your
request. The Plan says the services at issue are not covered benefits.
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 a limited
oral evaluation (D0140), an intraoral periapical radiographic image (D0220), and an extraction (D7140)
provided on April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on March 3, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for physician services. You say that you did not have time to obtain prior authorization for these services. 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 physician services provided on March 3, 2021 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 28, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 visit provided on September 28, 2020 by
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft - retained natural tooth - first site
in quadrant (D4263) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and
including elevation of mucoperiosteal flap if indicated (D7210) provided March 25, 2021.
You asked the Plan to pay for the bone replacement graft and tooth extraction. You say that a customer service representative failed to inform you that there was a requirement that the provider must not have opted-out of Medicare. The Plan denied your request. The Plan says this provider who has opted out of Medicare and therefore the services are 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. The Plan covers the bone replacement graft and tooth extraction when the services are medically necessary and reasonable. We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. The record includes a Medicare Private Contract provided by the oral surgeon and signed by you stating that services rendered by the oral surgeon's office would not be reimbursable under Medicare. Based on this information, we decided that the Plan's rules for coverage of the bone replacement graft and tooth extraction have not been met. Therefore, we decided that the Plan does not have to pay for the bone replacement graft - retained natural tooth - first site in quadrant (D4263) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided March 25, 2021.
Your complaint about potentially being provided incomplete information by a plan representative 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office evaluation services and x-ray of the pelvis provided on May 5, 2021.
You asked the Plan to pay for the office evaluation and x-ray. You say that you feel that these should be covered by the Plan. The Plan denied your request. The Plan says Medicare does not cover these services when provided by a chiropractor.
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 pay for the office evaluation services and x-ray of the pelvis provided on May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 5, 2021 by a
non-participating provider.
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 were rendered by a non-participating 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. 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 February 5, 2021 by a non-participating provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental healthcare after July 28, 2021.
You asked the Plan to pre-approve continued inpatient mental healthcare. You say that you need continued inpatient care. The Plan denied your request. The Plan says you can now be treated with outpatient care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued inpatient mental healthcare. Our reviewer says that continued inpatient care is not medically necessary. Our physician reviewer found based on the records provided, it is not expected that you would improve in a reasonable period of time beyond the dates in question as you are not showing any dangerousness to yourself or others, auditory or visual hallucinations, or aggressive behaviors. You have been compliant with treatment and are having no side effects to your medication. At this time, you could be treated in a lesser restrictive setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient mental healthcare have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental healthcare after July 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for treatments with a chemotherapeutic drug (J9303) provided on January 15 and 29 and February 12 and February 26, 2021, a CT scan of the thorax (71260) provided on January 13, 2021, and a transthoracic echocardiography (93306) provided on February 9, 2021.
You asked the Plan to waive the cost-sharing for a chemotherapeutic drug, a CT scan of the thorax, or a transthoracic echocardiography. You say that you need financial assistance with these bills. The Plan denied your request. The Plan says the correct cost-sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for chemotherapy drugs, a $275 copayment for CT scans when performed by a provider other than your primary care physician, and a $5 copayment for diagnostic procedures and tests. You have been asked to pay $1,786.19, or 20% of the Medicare-allowed charge of $8,930.93, for a chemotherapeutic drug provided on January 15, January 29, and February 12, 2021; and to pay $1,516.43, or less than 20% of the Medicare-allowed charge of $8,165.42, for a chemotherapeutic drug provided on February 26, 2021. A chemotherapeutic drug falls within the "Medicare Part B prescription drugs" benefit category. You have also been asked to pay a $275 copayment for a CT scan of the thorax and a $5 copayment for a transthoracic echocardiography. A CT scan of the thorax and a transthoracic echocardiography fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay less than or equal to 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 cost-sharing for treatments with a chemotherapeutic drug (J9303) provided on January 15 and 29 and February 12 and February 26, 2021, a CT scan of the thorax (71260) provided on January 13, 2021, and a transthoracic echocardiography (93306) provided on February 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for PET from the skull to thigh (78815) provided on April 22, 2021.
You asked the Plan to pay for the PET. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not submitted with a valid diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that CPT code 78815 is not supported in the record. Specifically, the Medicare Claims Processing Manual includes a list of diagnosis codes which are appropriate for PET services. The diagnosis code on the submitted claim is not listed as an appropriate diagnosis codes for PET services. Based on this information, we decided that Medicare rules for coverage of the PET have not been met. Therefore, we decided that the Plan does not have to pay for PET from the skull to thigh (78815) provided on April 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an echocardiogram provided on January 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for echocardiogram. You say that being a 24-hour provider facility you are not always aware that you need to have prior authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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. Although this Plan includes a Point-of-Service benefit, this
benefit is only covered when a covered referral is obtained.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for an echocardiogram provided on January 19, 2021
by an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for transitional care management services (99496) provided on February 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for transitional care management services. You say that please note that the enrollee is home bound. It was medically necessary, please reprocess. 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 transitional care management services (99496) provided on February 9, 2021 by an out-of-network (OON) provider.