Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the copayment for the laboratory work provided on February 15, 2021.

You asked the Plan to waive the copayment for the laboratory work. You say that the laboratory work was
done at a freestanding lab and not an outpatient hospital. The Plan denied your request. The Plan says that you
have been asked to pay the correct cost-sharing amount.

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 did not show the laboratory work was provided at an outpatient
hospital. The record does not show a place of service code which means we cannot verify where the laboratory
work was provided to the enrollee. Therefore, we decided that the Plan has to waive the copayment for the
laboratory work provided on February 15, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a periodontal maintenance (D4910) and bitewing x-rays (D0274) provided on April 11, 2018, to August 26, 2019. 

You asked the Plan to pay for a periodic oral evaluation, a periodontal maintenance and bitewing x-rays. You say that the provider's office failed to verify your insurance and submit the claims in a timely manner. The Plan denied your request. The Plan says claims must be submitted within one year following the date of service. 

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for a periodic oral evaluation, a periodontal maintenance and bitewing x-rays was not filed until August 4, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a periodontal maintenance (D4910) and bitewing x-rays (D0274) provided on April 11, 2018, to August 26, 2019. 

Your complaint about the provider's office failing to verify your insurance and submit the claims in a timely manner are 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110), intraoral complete series (D0210), and a comprehensive oral exam (D0150), provided on October 20, 2021.

You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan denied your request. The Plan says you received services out-of-network.

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 prophylaxis (D1110), intraoral complete series (D0210), and a comprehensive oral exam (D0150), provided on October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), periodontal maintenance (D4910) and bitewing x-rays (D0274) provided on April 11, 2019, to August 26, 2019.

You asked the Plan to pay for a periodic oral evaluation, periodontal maintenance and bitewing x-rays. You say that the provider's office failed to verify your insurance and submit the claims in a timely manner. The Plan denied your request. The Plan says claims must be submitted within one year following the date of service.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for a periodic oral evaluation, periodontal maintenance and bitewing x-rays was not filed until August 4, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), periodontal maintenance (D4910) and bitewing x-rays (D0274) provided on April 11, 2019, to August 26, 2019.

Your complaint about the provider's office failing to verify your insurance and submit the claims in a timely manner are 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontic maintenance (D4910), provided on November 17, 2021.

You asked the Plan to pay for the periodontic maintenance. You say that the service should be covered. The Plan denied your request. The Plan says you obtained this service through a provider who has opted out of Medicare.

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 periodontic maintenance (D4910), provided on November 17, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for air ambulance services provided to the enrollee on August 22, 2021.

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says that the request is not medically necessary, because the records show that transport was not to the nearest facility.

The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 pay for the services. Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found the enrollee was transported via air ambulance from Colorado to the facility for emergency heart surgery that was being managed by a specialist and the facility was the closest facility which was able to effectively perform the specific procedure (Amplatzer plugs for valve dehiscence). Previous trips to this facility for the same reason had been approved in the past, and there was no indication this trip was any different based on the provided records. The documentation does support that the enrollee suffers from an illness that contraindicates transportation by any means other than ambulance. The documentation does support that the enrollee's unique condition needed to transport the patient by air as ground transport would have posed a threat to the patient's survival or seriously endanger the enrollee's health. The documentation also supports that the transferring hospital did not have adequate facilities or expertise to perform the complex procedure required. 

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 services have been met. Therefore, we decided that the Plan has to pay for air ambulance services provided to the enrollee on August 22, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental surgery services provided in an outpatient hospital 
setting on May 18, 2021, to May 19, 2021. 
 
You asked the Plan to pay for the dental services. You say that this was a 30-minute surgery with prep and 
recovery, and no medications were provided other than anesthesia and gauze. You feel the cost of these 
services are unreasonable and this treatment should be covered. The Plan denied your request. The Plan says 
Medicare does not cover dental care except in limited circumstances. The oral surgery in this case was for 
dental extractions and an alveoloplasty due to dental caries. The Plan offers a supplemental dental benefit to 
cover additional services; however, the services provided are not among those covered by this 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. 
 
The services at issue are dental in nature and are not eligible for payment under Original Medicare. 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 dental surgery 
services provided in an outpatient hospital setting on May 18, 2021, to May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services rendered on October 29, 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 are not covered when performed by a chiropractor. 
 
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 service at issue is not manual manipulation of the spine. The file shows that the 
chiropractor billed procedure codes 99202 (office visit), 97140 (manual therapy techniques), and G0283 
(electrical stimulation). Therefore, we decided that the Plan does not have to pay for the chiropractic services 
rendered on October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventative procedure (D1999) provided on 
September 24, 2021. 
 
You asked the Plan to pay for the unspecified preventative procedure. You say that these services were 
necessary, and you were referred to this provider by the dental plan. The Plan denied your request. The Plan 
says they have agreed to cover the x-ray and the exam; however, the unspecified preventative procedure is not 
covered by your dental benefit, regardless of the participation status of the provider. 
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 
unspecified preventative procedure (D1999) provided on September 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core buildup (D2950) provided on 
December 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that you do not understand how you exceeded your 
$1,500 dental limit as you do not see previous dental claims in your history. The Plan denied your request. The 
Plan says you met and exceeded your annual maximum allowance for dental care on the date in question. You 
are responsible for any charges that exceed this allowance. 
 
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. The Plan pays a maximum of 
$1,500 toward the cost of covered dental services each year. 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services provided in excess of 
the annual dental allowance are not covered under this benefit. Documentation shows that the Plan paid $227 
for a filling provided to you on December 15, 2021, $202 for a cleaning, exam and fluoride treatment provided 
on December 18, 2021, and $1,071 toward the cost of the filling and crown provided on December 13, 2021. 
($1,071 + $202 + $227 = $1500). Documentation supports that the Plan has paid the full $1,500 allowance for 
your dental care in 2021. Therefore, we decided that the Plan does not have to pay for the crown (D2740) and 
core buildup (D2950) provided on December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) provided on December 14, 2021. 
 
You asked the Plan to pay for the limited exam. You say that this service was urgent due to a problem and 
should be covered. The Plan denied your request. The Plan says your dental benefit covers a maximum of two 
oral exams per year. You had a periodic oral exam on February 16, 2021, and August 31, 2021, which were 
covered by the Plan. The exam in question exceeds what is covered by your 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. The Plan can cover two oral 
exams per year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the exam is requested in a frequency 
that is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited 
oral exam (D0140) provided on December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an L300 Go System functional electrical stimulator (E0770) for the enrollee.

You asked the Plan to pre-approve an L300 Go System. You say that this is medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of the Electrical Stimulator device in the setting of post stroke residual hemiparesis has not been demonstrated in the peer-reviewed literature.

The Plan must follow Medicare rules.  Medicare rules say that a functional electrical stimulator is covered for the above indications.

We looked at the file and Medicare rules. The file does not indicate the enrollee is using this to treat muscle atrophy where nerve supply to the muscle is intact or being used to help walking because of a spinal cord injury. Based on this information, we decided that Medicare rules for coverage of an L300 Go System have not been met. Therefore, we decided that the Plan does not have to pre-approve an L300 Go System functional electrical stimulator (E0770) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopy (CPT code 76000) provided on March 23, 2021.  
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
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 76000 
is a column II code to column I code 63056. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the fluoroscopy (CPT code 76000) provided on March 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous passive motion machine received on August 17, 2021.

You asked the Plan to pre-approve the device. You say that you do not understand why this was not paid. The Plan denied your request. The Plan says this not covered under any normal circumstances.

The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program.

The rendering provider is not eligible to bill Medicare. the Plan did not pre-approve the device. The referring provider is not a participating provider with the plan. We found no exception that would require the Plan to pre-approve these items/services. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion machine received on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated resin crown (D2932) provided on July 14, 2021.

You asked the Plan to pay for the dental service. You say that you had a crack in the front of your crown over an implant. You say that you understand implants are not covered. You also say that you do not understand how cap is different if it was an implant or a tooth. The Plan denied your request. The Plan says fillings is not listed as a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the prefabricated resin crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prefabricated resin crown (D2932) provided on July 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on June 14, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an 
appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, CPT code 97110 was billed with CPT code 92526. We find that CPT code 97110 may be eligible 
for payment when billed with this code pair. The claim does not show that the code at issue was billed with a 
modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the physical 
therapy services provided on June 14, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on October 15, 2021. 
 
You asked the Plan to pay for wound care services. The Plan denied your request. The Plan says traditional 
Medicare is the primary payer. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on October 12, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for wound care services 
provided on October 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an arthrocentesis provided on October 19, 
2021. 
 
You asked the Plan to waive the copayment for an arthrocentesis. You say that you wanted to know why the 
Plan did not pay anything. The Plan denied your request. The Plan says you have been charged 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 $350 
copayment for in-network outpatient surgery at an outpatient hospital.  
 
 The record shows the Plan processed the claim correctly. You have been asked to pay the total allowed amount 
of $337.95, which is less than the $350 copayment for an arthrocentesis ($225.30 copayment + $112.65 
copayment = $337.95). An arthrocentesis falls within the Outpatient Surgery and Other Medical Services 
Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an arthrocentesis provided on October 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services (97810 x 8, 97811 x 8) provided 
from October 4, 2021, to November 22, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that the services should be paid. The Plan 
denied your request. The Plan says the provider in this case is not supervised by any physician, physician 
assistant (PA), nurse practitioner (NP), or certified nurse specialist (CNS). The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, [ADJUDICATOR ENTER CASE SPECIFICS]. 
Therefore, we decided that the Plan does not have to pay for the acupuncture services (97810 x 8, 97811 x 8) 
provided from October 4, 2021, to November 22, 2021.