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

We decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, and prophylaxis provided on February 23, 2021 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, first intraoral periapical x-ray, and prophylaxis. You say that you contacted the Plan multiple times and were not advised that this treating provider was OON. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.
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, you are responsible for 100% of the
cost for dental services that are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, and prophylaxis provided on February 23, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), panoramic x-ray (D0330), extraction (D7210), and unspecified preventive service (D1999) provided from March 25, 2021, to April 12, 2021.
You asked the Plan to pay for the dental services. You say that you needed your tooth to be extracted. You say that your dentist was not able to perform the extraction because you are on a blood thinner. You also say that this was not an elective procedure as you were experiencing a lot of pain. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per year. The Plan says that 1 panoramic x-ray is covered every 60 months. The Plan says that the frequency limits have been exceeded. The Plan also says that the extraction and unspecified preventive service are not listed as 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 and limited oral evaluation and panoramic x-ray are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on March 17, 2021. The record shows that the Plan paid for a panoramic x-ray that you received on June 7, 2018. Additionally, the extraction and unspecified preventive service are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), panoramic x-ray (D0330), extraction (D7210), and unspecified preventive service (D1999) provided from March 25, 2021, to April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on August 19, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed
incorrectly.
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or
proprietary laboratory analysis CPT code.
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple
code. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we
decided that the Plan does not have to pay for the genetic testing provided on August 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 25, 2020 by an
out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services
provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 August 25,
2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality tests (D0460) provided on April 20, 2021.
You asked the Plan to pay for the pulp vitality tests. You say that you feel this service should be covered. The Plan denied your request. The Plan says this service is 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, 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 pulp vitality tests (D0460) provided on April 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from March 17, 2021, to April 5, 2021.

You asked the Plan to waive the copayments for the physical therapy visits. You say that you were told that the service was covered by the Plan. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $25 copayment for each physical therapy and speech therapy session.

You have been asked to pay a $25 copayment for each the physical therapy visits. ($25 x 7 visits = $175). The physical therapy visits 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 the physical therapy visits provided from March 17, 2021, to April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on February 26, 2021 by an out-of-network provider.
You asked the Plan to pay for the office visit (99214) and routine venipuncture (36415). You say that it is not standard practice to get a prior authorization for an office visit. The Plan denied your request. The Plan says the provider did not obtain prior authorization as required.
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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the physician services provided on February 26, 2021 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit, chiropractic manipulative treatment (CMT); extraspinal, manual therapy technique or application of infrared modality provided on April 22, 2021 and April 27, 2021.

You asked the Plan to pay for office visit (99202), chiropractic manipulative treatment (CMT); extraspinal (98943), manual therapy technique (97140) and application of infrared modality (97026). You say that you were told multiple times your services were covered. The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for office visit, chiropractic manipulative treatment (CMT); extraspinal, manual therapy technique or application of infrared modality provided on April 22, 2021 and April 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (70544) provided February 4, 2021.

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed. This procedure cannot be separately paid.

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 70544 has a bundled relationship with code 70553 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (70544) provided February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 8, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the office visit provided on January 8, 2020 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from December 2, 2020 to December 27, 2020.
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.
We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that the home health services billed were provided to the enrollee, as there were no records for the billed December 2, 2020 to December 27, 2020 dates of service. Therefore, we decided that the Plan does not have to pay for the home health services provided from December 2, 2020 to December 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and appliance (E0673).
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 to treat PAD is not eligible for reimbursement. A PCD coded as E0675 is used only for peripheral artery disease. Other PCD codes are not used for this condition. PCD related accessories are eligible for reimbursement only when the appropriate, related base PCD meets coverage criteria for that type of PCD. The file shows CPT code E0675 was billed along with E0673 (x2). As E0675 is not eligible for payment, E0673 is also not payable in this case. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and appliance (E0673).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 5, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem.
The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay reimbursement for the acupuncture services (97810, 99203, 97811) provided May 21, 2021 to June 4, 2021.
You asked the Plan to pay reimbursement for the acupuncture services. You say that you were not aware of the out of network provider allowed amount of $35.91. You thought you would be reimbursed 50% of the total charge of $120 per visit. The Plan denied your request. The Plan says the claim was processed with the correct coinsurance applied per the Evidence of Coverage.
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 50% coinsurance per visit or when out of network, and the Plan will pay 50% of the allowance or acupuncturist's charges. You have been asked for reimbursement of $336.96. When services are received from an out of network provider, the Plan will pay 50% of the allowable or acupuncturist's charges. Whichever is less. You are responsible for balances up to the acupuncturist's charge. The Plan paid 50% of the allowable. the acupuncture services fall within the Acupuncture for chronic low back pain 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 pay reimbursement for the acupuncture services (97810, 99203, 97811) provided May 21, 2021 to June 4, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services represented by code 99153 provided on December 8, 2020.
You asked the Plan to pay for code 99153. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the review shows that the medical records provided represent professional charges; however, procedure code 99153 was provided in a facility with a place of service code of 24. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation services represented by code 99153 provided on December 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says this is being denied based on Medicare rules and personal care needs.

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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing or skilled therapy needs. While you receive enteral feeds, this is not new. You require total assistance for mobility and activities of daily living. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs are custodial, and 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80050 and 82947) provided on February 4, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services (80050 and 82947) provided on February 4, 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 September 30, 2020.

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 September 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrocardiogram (EKG) (93000) and office visit (99204) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an EKG and office visit to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 an electrocardiogram (EKG) (93000) and office visit (99204) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent.
You asked the Plan to pre-approve Praluent. You say that the enrollee is stable on this medication. The Plan denied your request. The Plan says Praluent to be administered at home is not covered under the Part B benefit.
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 Praluent.
Benefits for Praluent may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights