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

We decided that the Plan does not have to pay for the dental services provided on February 18, 2021 and May 19, 2021.
You asked the Plan to pay for the dental services. You say that you went out-of-network because you couldn't find anyone in your area that took your insurance. You say that you should have been told it wouldn't be paid. The Plan denied your request. The Plan says out-of-network dental 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on February 18, 2021 and May 19, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you will be out-of-the-area and believe it is a safer option to be able to see a doctor instead of going to an emergency room. You say this doctor has agreed to take you as a patient. The Plan denied your request. The Plan says the provider is 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oral exam (D0120), cleaning (D1110), and filling (D2330) provided from June 17, 2021, to June 28, 2021, provided by an out of network dentist.

You asked the Plan to reimburse you for the dental services. You say that you say that you when you signed up for the plan, you were advised that your dental visits would be covered. You say that no insurance company should tell you what dentist you can or cannot see. You also say that you would like some reimbursed. The Plan denied your request. The Plan says dental services are paid based on the in network fee schedule. The Plan says that out of network dentist have not agreed o provide services at contracted fees. The Plan also says that out of network dentists may bill you for any amount greater than what the Plan pays.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, out of network dentists may bill you for any amount greater than what the Plan pays. Therefore, we decided that the Plan does not have to reimburse you for the oral exam (D0120), cleaning (D1110), and filling (D2330) provided from June 17, 2021, to June 28, 2021, provided by an out of network dentist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on May 10, 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 G0483 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0483 is definitive drug testing, 22 or more drug classes. We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation of testing of 22 or more drug classes. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99221-24) provided on April 20, 2019.

You asked the Plan to pay for hospital care. You say that this service was provided in good faith. The Plan denied your request. The Plan says this is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that Modifier "-24" is used to report an unrelated evaluation and management service by same physician during a postoperative period. Services submitted with the "-24" modifier must be sufficiently documented to establish that the visit was unrelated to the surgery.

We looked at the file and Medicare rules. The documentation does not support that the hospital care at issue was unrelated to the surgery (28122) performed earlier that day. The records indicate that these services were provided to treat the same diagnoses. Based on this information, we decided that Medicare rules for coverage of hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99221-24) provided on April 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial nursing facility care provided on June 25, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the initial nursing facility care. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was 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. The records provided for review do not show that the services at issue were urgent or emergent.

Therefore, we decided that the Plan does not have to pay for the initial nursing facility care provided on June 25, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81406, 81405, 81404, 81403, 81402, 81401, 81400, 81321, 81318, 81314, 81311, 81310, 81299, 81293, 81276, 81275, 81272, 81270, 81235, 81210, 81121, 81120) provided on May 25, 2021.
You asked the Plan to pay for Guardant360 testing. You say that this is a covered service. The Plan denied your request. The Plan says this is not supported in the records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that code 81479 is used for Guardant360 testing.
We find that CPT codes 81406, 81405, 81404, 81403, 81402, 81401, 81400, 81321, 81318, 81314, 81311, 81310, 81299, 81293, 81276, 81275, 81272, 81270, 81235, 81210, 81121, and 81120 are not supported in the medical record. Specifically, these codes were used to report Guardant360 testing, which should be billed with 81479. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (81406, 81405, 81404, 81403, 81402, 81401, 81400, 81321, 81318, 81314, 81311, 81310, 81299, 81293, 81276, 81275, 81272, 81270, 81235, 81210, 81121, 81120) provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the dermatology visit you had on June 17, 2021
You asked the Plan to waive the copayment for the dermatology visit. You say that you were told that you would have a $0 copayment until June 30, 2021. You said that you were referred to this specialist by your primary care doctor. The Plan denied your request. The Plan says you were charged this copayment 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 $20 copayment for specialist visits. You have been asked to pay a $20 copayment for the dermatology visit. The dermatology visit falls within the specialist visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. Please note that according to your Plan's website, the Plan was only waiving copayments for telehealth visits or for COVID-related hospital admissions. There is no copayment waiver for specialist services, regardless of the reason. 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 dermatology visit you had on June 17, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scans of the chest, abdomen and pelvis you had on May 6, 2021.
You asked the Plan to waive the copayment for the CT scans. You say that you have never paid for this before. The Plan denied your request. The Plan says you were charged this copayment 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 $150 copayment for diagnostic radiology services. You have been asked to pay a $150 copayment for the CT scans. The CT scans fall within the diagnostic radiology 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 copayment for the computed tomography (CT) scans of the chest, abdomen and pelvis you had on May 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 3, 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 the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 13, 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 May 13, 2021 by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmological services provided on March 3, 2021.

You asked the Plan to waive the copayment for ophthalmological services. You say that the full copayment of $25.00 was paid already, and you should not owe another $5.00. The Plan denied your request. The Plan says a specialist's office visit for Medicare-covered vision services is a $30 copayment. This was not a regular specialist's office visit which does apply a $25 copayment.

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 $30 copayment for each specialist office visit for Medicare-covered vision services.

The enrollee has been asked to pay a $30 copayment for ophthalmological services. The ophthalmological services falls within the Vision Services (Medicare-covered) 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 ophthalmological services provided on March 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cervical dilation and cutterage procedure you received at an outpatient hospital facility on August 25, 2021.
You asked the Plan to waive the copayment for the outpatient surgery. You say that the doctor did not inform you that you would have to pay a portion of this service. You said that you do not believe this procedure was necessary, so you shouldn't have to pay. The Plan denied your request. The Plan says you were charged this copayment 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 $350 copayment for outpatient surgery at an outpatient hospital facility. You have been asked to pay a $350 copayment for the outpatient surgery. 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 cervical dilation and cutterage procedure you received at an outpatient hospital facility on August 25, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the definitive drug testing for 22 or more drug classes provided on May 19, 2021 billed with code G0483.
You asked the Plan to pay for the definitive drug testing as billed. You say that this is billed correctly and should be paid. The Plan denied your request. The Plan says that only 18 drug classes were counted on the lab report.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Code G0483 is for definitive drug testing of 22 or more classes. We find that CPT code G0483 is supported in the medical record. Specifically, the lab report clearly documents results for more than 22 billable classes as per the CPT code manual. Based on this information, we decided that Medicare rules for coverage of the definitive drug testing as billed have been met. Therefore, we decided that the Plan has to pay for the definitive drug testing for 22 or more drug classes provided on May 19, 2021 billed with code G0483.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.

You asked the Plan to pre-approve the power scooter. You say that the power mobility device is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 power scooter. Our reviewer says that the power scooter is not medically necessary. Our physician reviewer found there is no documentation to show that the enrollee can safely operate the device within the home. 

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 power scooter have not been met.

Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral exam (D0120) prophylaxis, cleaning (D1110) intraoral, periapical first x-rays (D0220) provided June 7, 2021.
You asked the Plan to pay for the dental services. You say that please reprocess this claim as you were unaware that this provider had opted out of Medicare. The Plan denied your request. The Plan says if you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 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. Therefore, we decided that the Plan does not have to pay for periodic oral exam (D0120) prophylaxis, cleaning (D1110) intraoral, periapical first x-rays (D0220) provided June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral-periapical radiographic image (D0220), and sales tax (D9985) provided by a participating provider on May 25, 2021.

You asked the Plan to pay for a limited oral evaluation, intraoral-periapical radiographic image, and sales tax. You say that this dental work is medically necessary. You say that you chipped your tooth on a piece of candy. The Plan denied your request. The Plan says the dental services that were provided are not covered 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. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral-periapical radiographic image (D0220), and sales tax (D9985) provided by a participating provider on May 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated abutment and abutment supported crown provided on July 27, 2021.
You asked the Plan to pay for the prefabricated abutment and abutment supported crown. You say that the type of work listed is not the type of work that relates to what you had done. You say that you understand coverage can change but the work you are requesting reimbursement for did not change. The Plan denied your request. The Plan says the services 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 the prefabricated abutment and abutment supported crown provided on July 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cataract surgery you had at an ambulatory surgery center on July 12, 2021.

You asked the Plan to waive the copayment for the cataract surgery. You say that you called the plan a week before surgery to see if you would have one copayment or two. You said that you were told there would only be one copayment for both cataract procedures. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan reviewed the phone records from your call to determine what you were told. During that call, the Plan says you were advised of the copayment for outpatient surgery, but there is no record of multiple procedures being discussed.

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 $350 copayment for outpatient surgery at an ambulatory surgery center.

You have been asked to pay a $350 copayment for the cataract surgery. This copayment applies on a per-service basis. You had two separate surgeries, so two copayments apply. 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 cataract surgery you had at an ambulatory surgery center on July 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower/bath chair.
You asked the Plan to pre-approve a shower/bath chair. You say that this equipment is medically necessary. The Plan denied your request. The Plan says shower and bath equipment is not covered by Medicare.
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 shower/bath chair 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 shower/bath chair.