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

We decided that the Plan does not have to pay for periapical x-rays (D0230x2) provided November 12, 2019.
You asked the Plan to pay for the dental services. You say that the receptionist at the provider's office had called the plan and had confirmed your coverage, confirmed that the doctor was in network and your coverage benefits. The Plan denied your request. The Plan says the benefit frequency has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. This service is allowed once every year. The plan has approved 1 x-ray for this date of service. Therefore the other 2 x-rays are not covered. 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 periapical x-rays (D0230x2) provided November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed and mattress overlay for the enrollee.
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary at this time.
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 items. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not indicate there is need for immediate and/or frequent position changes, and/or special attachments that cannot be fixed to an ordinary bed. As such, this request is not medically 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 the items have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed and mattress overlay for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on February 22, 2020 by an out of network (OON) provider.
You asked the Plan to pay for radiology services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is 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 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 radiology services provided on February 22, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder orthosis provided on February 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these OON items. 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 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 shoulder orthosis provided on February 5, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the antibody stain procedure provided on July 10, 2019
You asked the Plan to pay for the provided service. You say that the service was provided in addition to the original procedure for July 9, 2019. The Plan denied your request. The Plan says that the date of the test/service must be the date the specimen was collected.
The Plan must follow Medicare rules. Medicare rules say that if a specimen is collected over a period that spans two calendar days, then the DOS must be the date the collection ended.
In this case, the CPT Code Manual definition of code 88341 is immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure). We find that CPT code 88341 is supported in the medical record. Based on the information provided, we decided that Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pay for the antibody stain procedure provided on July 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 62321 provided on December 19, 2019.
You asked the Plan to pay for the injection 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 supported by the documentation.
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 62321 is injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT). We find that CPT code 62321 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of injection(s), of diagnostic or therapeutic substance(s) not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services coded 62321 provided on December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the topical application of fluoride varnish (D1206), the gingival irrigation (D4921 x 4), periodontal maintenance (D4910), the complete series of periapical x-rays (D0210), the extraction (D7140), and the filling (D2392) provided from April 3, 2019 to April 29, 2019. 
 
You asked the Plan to pay for the dental services. You say that the plan agent that signed you up for this plan, effective April 1, 2019, did not advise that you did not have dental coverage. You say that you had been paying your monthly dental premium because you were under the impression that you still had it. You say that you did not realize you did not have coverage until you received refund checks. The Plan denied your request. The Plan says you were not actively enrolled in the dental rider on the dates of service. The Plan says that since you were not enrolled in the dental rider, the services remain your financial responsibility. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the topical application of fluoride varnish (D1206), the gingival irrigation (D4921 x 4), periodontal maintenance (D4910), the complete series of periapical x-rays (D0210), the extraction (D7140), and the filling (D2392) provided from April 3, 2019 to April 29, 2019.  
 
Your complaint about not being signed up for the supplemental dental plan 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tub stool or bench for the enrollee.
You asked the Plan to pre-approve a tub stool or bench. You say that this is needed to alleviate the enrollee's pain and physical risk in the bathtub. The Plan denied your request. The Plan says that this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a tub stool or bench may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a tub stool or bench for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of an endosteal implant (D6010), the prefabricated abutment (D6056), and the bone graft at the time of the implant placement (D6104) provided on December 10, 2019. 
 
You asked the Plan to pay for the dental services. You say that the enrollee had been experiencing pain and pressure. You also say that the enrollee's current dentition is a result of harsh chemotherapy that he has undergone in the past. The Plan denied your request. The Plan says the services that were rendered to the enrollee were dental in nature. The Plan also says that the implant services are not covered under the enrollee's medical 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 services you received involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the surgical placement of an endosteal implant (D6010), the prefabricated abutment (D6056), and the bone graft at the time of the implant placement (D6104) provided on December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve frames and lenses provided January 6, 2020.
You asked the Plan to pre-approve the eyeglasses. You say that you didn't know that the 2020 plan would not cover out-of-network vision. The Plan denied your request. The Plan says only vision services provided in-network are eligible for coverage.
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. The Plan covers these services when they are received from in-network providers. We looked at the file and the Plan's rules. The services were received from an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pre-approve frames and lenses provided January 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the abscess aspiration provided on November 11, 2019.  
 
You asked the Plan to waive the copayment for the abscess aspiration. You say that you only had one procedure. You say that there are duplicate charges. 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 $250 copayment for Medicare-covered surgery or other services at an in-network outpatient hospital or ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. 
 
You have been asked to pay a $250 copayment for the abscess aspiration. The abscess aspiration falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The abscess aspiration is considered a surgical procedure. 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 abscess aspiration provided on November 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a transcatheter aortic valve replacement (TAVR) (33361) provided on October 22, 2019.
You asked the Plan to pay for a transcatheter aortic valve replacement. You say that these services were ordered by a in-network surgeon. The Plan denied your request. The Plan says this service is only covered if the enrollee is in an approved clinical trial.
The Plan must follow Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services (CMS) covers transcatheter aortic valve replacement (TAVR) under Coverage with Evidence Development (CED). We looked at the file and Medicare rules. The file does not show that the enrollee is enrolled in a CED trial. Based on this information, we decided that Medicare rules for coverage of a transcatheter aortic valve replacement have not been met. Therefore, we decided that the Plan does not have to pay for a transcatheter aortic valve replacement (TAVR) (33361) provided on October 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on November 26, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan
requires utilization of network providers when possible and available, and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
laboratory services. 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 laboratory services provided on November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 30, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan
requires utilization of network providers when possible and available, and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
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 physician's services provided on December 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames and lenses purchased December 24, 2019 
 
You asked the Plan to pay for the vision services. You say that you are appealing the decision to deny your claim for eyeglasses. The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network provider. 
 
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. The Plan covers these services when provided by a network vision provider. 
 
We looked at the file and the Plan's rules. You must use a network vision provider for the eye wear benefit. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the frames and lenses purchased December 24, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the venous catheter insertion and CT scan provided on December 2, 2019 and December 3, 2019.
You asked the Plan to waive the copayment for the venous catheter insertion and CT scan. You say that you had pain and had to return to the hospital. You say that you should only owe for the ER visit. The Plan denied your request. The Plan says the copayments 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 $325 copayment for surgical services at an in-network outpatient hospital facility. Your contract with the Plan clearly says that you must pay a $225 copayment for each in-network, Medicare-covered advanced imaging service. If advanced imaging services are received as part of an emergency department evaluation then you will only pay the advanced imaging copayment, not the emergency room copayment. You have been asked to pay a $325 copayment for the venous catheter insertion and a $225 copayment for the CT scan. The total amount you owe is $550 ($325 + $225 = $550). The venous catheter insertion falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The CT scan 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 the venous catheter insertion and CT scan provided on December 2, 2019 and December 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental extractions (D7140) provided January 3, 2020. 
 
You asked the Plan to pay for the extractions. You say that the service should be covered. The Plan denied your request. The Plan says this dental service is not a covered benefit under your plan. 
 
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 dental extractions (D7140) provided January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 14, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan
requires utilization of network providers when possible and available, and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
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 physician's services provided on November 14, 2019.