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

We decided that the Plan does not have to pay for the crown (D2750) and core buildup, including any pins when required (D2950) provided on February 1, 2021.
You asked the Plan to pay for the crown and core buildup. You say that the Plan never advised you that your dental coverage had changed or that there were any other plan options. The Plan denied your request. The Plan says these services are not covered by the 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 the crown (D2750) and core buildup, including any pins when required (D2950) provided on February 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screening (81407, 81408) provided on January 25, 2021.
You asked the Plan to pay for a hereditary cardiovascular screening. You say that this is supported by the records. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular screening have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular screening (81407, 81408) provided on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction services or waive the copayment for the medical eye exam services provided on June 8, 2021.
You asked the Plan to pay for the eye refraction services or waive the copayment for the medical eye exam services. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you are responsible for the $35 copayment for each visit to an ophthalmologist for Medicare-covered benefits, additionally eye refractions are only covered when performed as a routine service. Your claim was billed with a medical diagnosis for the presence of intraocular lens.
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 file and the Plan's rules. In this case, the Plan contract clearly says you are responsible for a $35 copayment for each visit to an ophthalmologist for Medicare-covered benefits. Additionally, eye refractions are only covered when performed as a routine service. Your claim was billed with a medical diagnosis for the presence of intraocular lens. You are responsible for the $64 total payment per your Plan benefits. Therefore, we decided that the Plan does not have to pay for the eye refraction services or waive the copayment for the medical eye exam services provided on June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for morphometric analysis (88369) provided on March 26, 2021.
You asked the Plan to pay for the morphometric analysis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 81219 and 88369.
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 88369 has a bundled relationship with code 81219 and cannot be paid as billed. This code cannot be paid as a separate line item. The claim has not been billed with a modifier to indicate that this was a distinct service. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for morphometric analysis (88369) provided on March 26, 2021.
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 in the Medicare rules section 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 you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level of 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 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 pre-approve Hydroxyzine Pamoate 25mg for the enrollee.
You asked the Plan to pre-approve this is medically necessary.. You say that this is medically necessary. The Plan denied your request. The Plan says this is a self-administered 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 pre-approve Hydroxyzine Pamoate 25mg for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for FoundationOne testing (81455) provided on March 23, 2021.
You asked the Plan to pay for FoundationOne testing. You say that this is supported. The Plan denied your request. The Plan says that the ordering provider did not order genetic testing.
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 states that they contacted the ordering provider, who said that they did not order genetic testing. However, they did not include documentation of this outreach. There is also a signed order in the file, and the submitted medical records include an office visit note in which the provider states that they are requesting the testing at issue. The Plan has not submitted information or documentation supporting that the order is not valid. Therefore, we decided that the Plan has to pay for FoundationOne testing (81455) provided on March 23, 2021.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on February 5, 2021.
You asked the Plan to pay for these services. 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.
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 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 to the enrollee on February 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided January 16, 2020, to January 22, 2020, and February 12, 2021, to February 18, 2021.
You asked the Plan to waive the copayment for two inpatient hospital stays. You say that it is difficult to pay and catch up on copays. The Plan denied your request. The Plan says the copayment was 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $475 copayment per day for days 1-4 of an acute care hospital admission.
The enrollee has been asked to pay a total of $3,800 (($475 copayment x 4 days) + ($475 copayment x 4 days) = $3,800) for the two inpatient hospital stays. These hospital stays fall within the Inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided January 16, 2020, to January 22, 2020, and February 12, 2021, to February 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthroscopy, shoulder, surgical; with rotator cuff repair (29827) for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the information documented in the medical notes is insufficient to determine if surgery is the members only option for treatment.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. There is no documentation of recent and adequate trial of physical therapy for shoulder pain. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve arthroscopy, shoulder, surgical; with rotator cuff repair (29827) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the vascular study rendered on April 1, 2021.
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 93976 is not supported.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 93976 (vascular study) and 76856 (complete pelvic ultrasound). Code 93976 is a column II code with a modifier indicator of 1 when billed with column I code
76856. Code 93976 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the vascular study rendered on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on February 24, 2021.
You asked the Plan to pay for out of network physician services. . You say that you prefer to see the requested provider and do not understand while the Plan will not allow this. The Plan denied your request. The Plan says you did not have prior authorization for 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 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 out of network physician services provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on March 9, 2021.
You asked the Plan to pay for these services. 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.
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 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 out of network physician services provided to the enrollee on March 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of a lower extremity joint.
You asked the Plan to pre-approve an MRI of a lower extremity joint. 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. Medicare rules say that MRIs are covered only when they are medically necessary. 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 an MRI of a lower extremity joint. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has knee degenerative joint disease (djd) and is scheduled for knee replacement surgery. An mri is not medically needed prior to this surgery. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of a lower extremity joint have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of a lower extremity joint.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth services (99421) provided on January 2, 2021.
You asked the Plan to pay for the telehealth services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
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 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 telehealth services (99421) provided on January 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and
services provided June 28, 2021, to June 30, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not agree with
the copay and cannot afford it. The Plan denied your request. The Plan says the copayment was 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 $370
copayment per day for days 1-5 of for each inpatient admission per benefit period.
You have been asked to pay a total of $740 ($370 copayment x 2 days = $740) for the inpatient hospital stay.
This hospital stay falls within the Inpatient hospital 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 waive
the copayment for the inpatient hospital admission and services provided June 28, 2021, to June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), and clinic service (T1015) provided on May 13, 2021 by an OON provider.
You asked the Plan to pay for the problem focused limited oral evaluation, intraoral periapical x-rays, and clinic service. You say that you were not aware that all of the providers in the dental office did not accept your insurance plan. You also say that they just advised you that you would be covered. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that non-emergency services provided by an OON provider are not available with this dental 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), and clinic service (T1015) provided on May 13, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse $375 for chiropractic services provided from October 5, 2020, to December 2, 2020.
You asked the Plan to reimburse this cost share. You say that you thought chiropractic care was covered in full. The Plan denied your request. The Plan says a $15 copayment was applied for those services allowed by Medicare and there is a $150 charge for services not related to manual manipulation of the spine. The Plan says that $225 in copayments and $150 for uncovered services equipment $375.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The contract with the Plan clearly says that enrollees must pay a $15 copayment for each chiropractic visit related to manual manipulation of the spine. Any services other than manual manipulation will not be covered. Therefore, we decided that the Plan does not have to reimburse $375 for chiropractic services provided from October 5, 2020, to December 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on April 7, 2021.
You asked the Plan to pay for the ambulance services. You say that while at church you had a fainting spell due to a condition you have experienced before, and an ambulance was called without your knowledge or consent. You say that you refused ambulance transport as you believe it was not needed and you should not be charged because you didn't need the ambulance and did not want to go to the hospital. The Plan denied your request. The Plan says according to Medicare, the ambulance benefit is a transportation benefit. If no transport occurs, this not considered to be a Medicare covered service.
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 April 7, 2021. 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 ambulance services provided on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on February 12, 2021.
You asked the Plan to pay for the office visit. You say that the doctor is in-network with the Plan and you have a lot of paid examples in the past. You say that based on the paid examples the claim should be processed for the denied date of service as soon as possible. The Plan denied your request. The Plan says prior authorization for out-of-network services 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 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 by an out-of-network provider on February 12, 2021.