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

We decided that the Plan does not have to pay for the incomplete endodontic therapy (D3332) provided on June 22, 2021.

You asked the Plan to pay for the incomplete endodontic therapy (D3332). You say that you had a root canal done after being told the service would be covered. You say that you now have a balance of $423 and are appealing the denial. The Plan denied your request. The Plan says the service is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the 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 incomplete endodontic therapy (D3332) provided on June 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound coded 76705 provided on March 31, 2021.
You asked the Plan to pay for the ultrasound. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
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 76705 for the ultrasound has a bundled relationship with code 93976 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 the ultrasound coded 76705 provided on March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous surgery, 4 or more contiguous teeth per quadrant (D4260), bone replacement graft (D4263 x 2), guided tissue regeneration (D4266 x 2), osseous surgery, 1 to 3 contiguous teeth per quadrant (D4261), and the consultation (D9310) provided on April 23, 2021.
You asked the Plan to pay for the dental services. You say that you have a new insurance policy. You also say that this claim should be reprocessed according to the new policy. The Plan denied your request. The Plan says the services you received are not listed as covered service under the optional supplemental dental coverage.
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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the osseous surgery, 4 or more contiguous teeth per quadrant (D4260), bone replacement graft (D4263 x 2), guided tissue regeneration (D4266 x 2), osseous surgery, 1 to 3 contiguous teeth per quadrant (D4261), and the consultation (D9310) provided on April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor (cgm) supplies provided on March 29, 2021.
You asked the Plan to pay for the therapeutic continuous glucose monitor (cgm) supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file shows that there was a delivery ticket in the case file, but it was not signed by the receiver of the supplies. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor (cgm) supplies provided on March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the upper partial denture with flexible base (Valplast)
(D5225) provided on May 12, 2021.
You asked the Plan to pay for the dental item. You say that you had to have a tooth pulled due to a severe
crack. You say that you needed something to fill the space. You say that the Valplast is the most cost-efficient
option. You also say that this should be covered. The Plan denied your request. The Plan says the partial upper
denture with flexible base is not listed as a covered dental item.
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 partial upper denture with flexible
base is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay
for the upper partial denture with flexible base (Valplast) (D5225) provided on May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete
series x-ray (D0210) provided on January 12, 2021.

You asked the Plan to pay for the dental services. You say that you were told that the services would be
covered. The Plan denied your request. The Plan says comprehensive oral evaluation is covered once every 3
plan years. The Plan says that complete series x-ray is covered once every 3 plan years. The Plan also says that
the frequency limits have been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental
services when the services are medically necessary and reasonable.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the dental services have not been met. Specifically, the frequency limits have been exceeded. The
record shows that the Plan paid for these services that you received on October 29, 2019, less than 3 years ago.
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and
complete series x-ray (D0210) provided on January 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for pacemaker insertion surgery provided on April 1, 2021.
You asked the Plan to waive the coinsurance for outpatient surgery. You say that if you had stayed at the hospital overnight your cost-sharing would be $250, so you are requesting reconsideration of this claim. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.
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 20% coinsurance for outpatient surgery at an outpatient hospital facility. The allowed amount of this claim is $9,582.07; however, you have been asked to pay $1,713.30 which is less than 20% coinsurance for this claim.
You have been asked to pay $1,713.30, which is less than 20% coinsurance for outpatient surgery. Outpatient surgery 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 coinsurance for pacemaker insertion surgery provided on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 provided on September 21, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 11; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a Skilled Nursing Facility setting place of service 31. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 provided on September 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more toward the dental services provided on December 14,
2020, December 28, 2020, May 1, 2021 and May 24, 2021.
You asked the Plan to pay more toward the dental services. You say that the customer representative said you
would be allowed to have $500 in benefits whenever you visit any dentist. You say that the Plan is required to
rework the claims. The Plan denied your request. The Plan says the claims processed correctly.
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 Plan is only obligated to pay the allowed amount for your covered dental services from an out-of-network provider. You are responsible for the full amount by which the actual charges of an out-of-network dentist exceed the allowable charge. The Plan paid $500 toward the dental services received in 2020 and paid the allowed amount of the charges for the covered dental services in 2021. You are responsible for the full cost of the surgical extraction as it is not a covered benefit. Therefore, we decided that the Plan does not have to pay more toward the dental services provided on December 14, 2020, December 28, 2020, May 1, 2021 and May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355), and intraoral - periapical first radiographic image (D0220) provided May 5, 2021.
You asked the Plan to pay for the bitewing x-rays, full mouth debridement and intraoral x-rays. You say that you called ahead to verify the copayments for services and do not understand why you are responsible for the full amount. The Plan denied your request. The Plan says the services were provided OON, and therefore 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. The Plan covers the bitewing x-rays, full mouth debridement and intraoral x-rays when the services are medically necessary and reasonable. We looked at the file, and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the bitewing x-rays, full mouth debridement and intraoral x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355), and intraoral - periapical first radiographic image (D0220) provided May 5, 2021.
Your complaint about potentially receiving confusing or incomplete information from a Plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the joint aspiration procedures you had at an outpatient hospital facility from February 3, 2021, to May 12, 2021.
You asked the Plan to waive the copayments for the joint aspiration procedures. You say that these procedures were not done in a hospital, but in a doctor's office. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that the facility where you had these services is part of a hospital system and that is why the outpatient hospital copayment applies.
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 $100 copayment for outpatient procedures/surgery at an outpatient hospital.
You have been asked to pay a $100 copayment for the joint aspiration procedures. The joint aspiration procedures fall within the outpatient procedures/surgery at an outpatient hospital benefit category. Records show that the Plan sent you a letter in late 2020 that advised you that if you receive services at locations owned by a hospital, the hospital copayment will apply, even if the services are not provided on hospital grounds. 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 joint aspiration procedures you had at an outpatient hospital facility from February 3, 2021, to May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (99100) provided on July 10, 2020.
You asked the Plan to pay for anesthesia services. You say that this should be covered. The Plan denied your request. The Plan says this is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified. We looked at the file and Medicare rules. The billed code, 99100, has a status indicator of B. Payment for this service is included in payment for other services. Based on this information, we decided that Medicare rules for coverage of anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99100) provided on July 10, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care services for 48 hours a week.

You asked the Plan to pre-approve the personal care services. You say that the presence of an attendant is greatly needed to assist the enrollee's functional impairment in performing personal daily tasks. The Plan denied your request. The Plan says coverage for the personal care services for 48 hours a week stating that requirements for coverage have not been met.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.

 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 personal care services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.

Our physician reviewer found based on the medical records provided there is no documentation that the services meet the definition of home health aide services as per Sections A, B, C, D & E of Section 50.2 and there is no documentation that the home health aide services are reasonable and necessary to the treatment of the patient's illness or injury by the skilled professional staff. The provided records do not document a skilled home health need or service; in the absence of a skilled home health need or service, home health aide services are not covered. 

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 personal care services have not been met. Therefore, we decided that the Plan does not have to pre-approve personal care services for 48 hours a week.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided form May 29, 2021, to June 4, 2021.

You asked the Plan to pay for the inpatient hospital care. You say that the services should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided form May 29, 2021, to June 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory and urgent care services provided on January 2, 2021.

You asked the Plan to pay for the laboratory and urgent care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99212 is not eligible for payment on an outpatient hospital claim.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory and urgent care services have not been met. Specifically, these services were billed on an outpatient claim. Under the Outpatient Prospective Payment System (OPPS), CPT code 99212 has a payment status indicator of B. This means that CPT code 99212 is a code that is not recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x and 13x). Therefore, we decided that the Plan does not have to pay for the laboratory and urgent care services provided on January 2, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the anesthesia provided on May 25, 2021.

You asked the Plan to pay for the anesthesia. You say that the claim was billed appropriately, and payment should be reconsidered. The Plan denied your request. The Plan says that the services are not covered under the medical 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. The Plan covers anesthesia as needed with covered dental procedures. We looked at the Evidence of Coverage, the case file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the anesthesia have been met. Specifically, anesthesia is listed as a covered benefit as needed with covered dental procedures as a mandatory supplemental dental benefit. Therefore, we decided that the Plan has to pay for the anesthesia provided on May 25, 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.