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

We decided that the Plan does not have to pay for the extraction (D7210), the bone replacement graft (D7953), the implant (D6010), and the unspecified implant procedures (D6199 x 2) provided on June 4, 2020.
You asked the Plan to pay for the dental services. You say that you were under the impression that your insurance would pay $1,000 for dental work. The Plan denied your request. The Plan says the services that were performed are not covered dental 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, the requested items or services are not among those covered under this benefit. The record shows that you do not have coverage for comprehensive dental services. Additionally, the 2018 Evidence of Coverage clearly states there is an allowance of $150 for preventive services. Therefore, we decided that the Plan does not have to pay for the extraction (D7210), the bone replacement graft (D7953), the implant (D6010), and the unspecified implant procedures (D6199 x 2) provided on June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 molecular pathology testing provided October 13, 2020.
You asked the Plan to pay for the Guardant360 molecular pathology testing. You say that you are requesting reconsideration of this claim and provide full reimbursement against the enrollee's in-network benefits for Guardant360. The Plan denied your request. The Plan says there is a more appropriate code to describe the services provided. Providers must not unbundle the services described by a HCPCS/CPT code.
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 is not supported in the medical record. Specifically, there is a more appropriate code to describe the services provided. Medicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic profiling for breast cancer and the appropriate DEX Z-Code identifier must be entered adjacent to the CPT code 81479 in the comment/narrative field. Providers must not unbundle the services described by a HCPCS/CPT code. Based on this information, we decided that Medicare rules for coverage of the Guardant360 molecular pathology testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 molecular pathology testing provided October 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleaning and inspection of a removable partial denture (D9934) provided on December 3, 2020.
You asked the Plan to pay for the dental service. You say that your dentist has been submitting similar claims for 3 years. You say that they have never been denied. You say that you do not understand why this service has been denied. You also say that you strongly believe these charges are covered through your plan. The Plan denied your request. The Plan says cleaning and inspection of a removable partial denture is not listed as a covered service. The Plan also says that your previous dental claims do not include this 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 cleaning and inspection of a removable partial denture (D9934) provided on December 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on January 5, 2021.
You asked the Plan to pay for a comprehensive oral evaluation. You say that you feel like the service should be covered. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 3 years.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on February 13, 2019. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on January 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on January 7, 2021.
You asked the Plan to waive the copayment for an MRI. You say that the MRI was medically necessary and you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $160 copayment for diagnostic radiology other than a CT scan. You have been asked to pay a $160 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies 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 MRI provided on January 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on September 29, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on September 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 27, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on July 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for re-cementing or re-bonding of a crown (D2920) provided on November 20, 2020.
You asked the Plan to pay for re-cementing or re-bonding of a crown. You say that this service was necessary. The Plan denied your request. The Plan says this service is not covered by Medicare or by your Plan's supplemental dental 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 re-cementing or re-bonding of a crown (D2920) provided on November 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided
from November 24, 2020, to December 11, 2020.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you request
assistance for the copayments. The Plan denied your request. The Plan says the claims were processed correctly
and you are being charged the correct amount.
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 $35
copayment for outpatient rehabilitation services.
You received outpatient rehabilitation services from November 24, 2020, to December 11, 2020, for a total of 3
visits. Therefore, you are responsible to pay a $35 copayment per each visit. The total amount you owe is: $35
(copayment) x 3 (outpatient rehabilitation services) = $105.
You have been asked to pay the total copayment amount of $105 for outpatient rehabilitation services.
Outpatient rehabilitation services fall within the outpatient rehabilitation services 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 copayments for outpatient rehabilitation services provided from November 24,
2020, to December 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the hysteroscopy and related services provided from December 7, 2020, through December 11, 2020.
You asked the Plan to waive the coinsurance for the hysteroscopy and related services. You say that you were told you would have a $150 copayment prior to treatment, which you paid at the time of service. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for surgery performed at an in-network outpatient hospital facility. You have been asked to pay $476.75, which is 20% of the allowed amount for the hysteroscopy and related services. The allowed amount is $2,383.74 (20% x $2,383.74 = $476.75). The hysteroscopy and related services fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 coinsurance for the hysteroscopy and related services provided from December 7, 2020, through December 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray (72110) provided October 1, 2020.
You asked the Plan to waive the copayment for the x-ray. You say that the x-ray copayment should have been included in your office visit. 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 $10 copayment for x-rays. You have been asked to pay the Medicare allowed amount of $5 for the x-ray. The allowed amount is less than the $10 copayment listed in the plan contract. 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 x-ray (72110) provided October 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 6, 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 November 6, 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 November 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mammogram and ultrasound provided on November 18, 2020.
You asked the Plan to waive the copayment for the mammogram and ultrasound. You say that you went for your yearly mammogram that insurance has always paid for. You say that you did not ask for the ultrasound and should not be billed for this. The Plan denied your request. The Plan says the copayment 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 $100 copayment for each Medicare-covered diagnostic procedure and test at an in-network outpatient hospital facility. You have been asked to pay a $100 copayment for the mammogram and ultrasound. The mammogram and ultrasound fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The mammogram and ultrasound are considered a diagnostic service. 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 mammogram and ultrasound provided on November 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on July 30, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these tests is correct, because these tests are not covered for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal, lab tests, were requested for screening purposes. Medicare does not cover these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that prior authorization was not required. The Plan denied your request. The Plan says there are in-network providers available 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 physician services provided on November 4, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are making good progress and require some specialty services that could be more closely monitored at the IRF. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount fora periodic oral evaluation (D0120), teeth cleaning (D1110), and a resin-based composite (D2332) provided from October 20, 2020, through December 2, 2020.You asked the Plan to pay an additional amount fora periodic oral evaluation, teeth cleaning, and a resin-based composite. You say that you would like the Plan to pay an additional amount towards the services.The Plan denied your request. The Plan says the claims for these services were processed correctly with the applicable out-of-network allowable amount paid.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, teeth cleaning, and a resin-based composite have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Any amount beyond the allowed amount is your contractual responsibility. Therefore, we decided that the Plan does not have to pay an additional amount foraperiodic oral evaluation (D0120), teeth cleaning (D1110), and a resin-based composite (D2332) provided from October 20, 2020, through December 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from October 13, 2020,
through October 15, 2020.
You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says that
hospital did not get approval from your medical group to admit you inpatient.
The Plan's contract says that an authorization is required for an inpatient admission.
We looked at the file and the Plan's rules. Based on this information, we decided that Medicare rules for
coverage of the inpatient admission have not been met. Therefore, we decided that the Plan does not have to
pay for an inpatient admission provided from October 13, 2020, through October 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on October 29, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on October 29, 2020.