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

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on August 10, 2021.

You asked the Plan to pay for periodontal maintenance. You say that you do not understand why this claim was denied, and the Plan has failed to clarify this information. The Plan denied your request. The Plan says the provider in this case does not participate in the Medicare program and has opted out. You must see a provider who accepts Medicare patients in the United States and has not opted out of Original Medicare in order to have dental care 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 requires supplemental dental care to be performed by a provider who has not opted out of Original Medicare in order for services to be eligible for coverage. 

Though the Plan offers a dental benefit in excess of Medicare coverage, items or services performed by a provider who has opted out of Original Medicare are not covered under this benefit. Documentation shows that this provider has opted out and does not participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns (D2740) provided on September 9, 2021.

You asked the Plan to pay for the crowns. You say that you cannot believe that the Plan is not going to help you pay for these crowns. You also say that you need financial assistance. The Plan denied your request. The Plan says your benefits for this service has been satisfied and the frequency limitation has been exceeded. The Plan also says that neither you nor the provider contacted 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, crowns are limited to two procedure codes per calendar year. The record shows that you received five crowns (D2740 x5) on September 9, 2021, two of which were covered by the Plan, and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the crowns (D2740) provided on September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on October 11, 2021.

You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says you do not have
out-of-network benefits to be reimbursed for vision services.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided through the Plan's vision network provider. 

We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided through the Plan's vision network provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on October 11, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the microslide consultation (88321) provided on May 21, 2021.  

You asked the Plan to pay for the lab service. You say that the service 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 microslide consultation (88321) provided on May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT image capture (D0383), guided tissue regeneration (D4266), two surgical removals of implant bodies (D6100 x2), collection and application of autologous blood concentrate product (D7921), two bone replacement grafts for ridge preservation (D7953 x2), and consultation (D9310) provided on April 28, 2021, and May 11, 2021.

You asked the Plan to pay for the cone beam CT image capture, guided tissue regeneration, surgical removals of implant bodies, collection and application of autologous blood concentrate product, bone replacement grafts, and consultation. You say that you were told that these services would qualify for the medical part of your plan's policy, and would not be processed by the dental policy. The Plan denied your request. The Plan says these services are not covered expenses under your dental plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam CT image capture (D0383), guided tissue regeneration (D4266), two surgical removals of implant bodies (D6100 x2), collection and application of autologous blood concentrate product (D7921), two bone replacement grafts for ridge preservation (D7953 x2), and consultation (D9310) provided on April 28, 2021, and May 11, 2021.

Please Note: The Plan forwarded this appeal information to the medical department for review to see if these services can be covered under your medical plan. Please contact the Plan for more information.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 28, 2021.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you did not know there was a limit of 36 months for this service which is why the enrollee agreed to receive it. You also say that this service should be paid to the provider because it is not their fault nor is it the enrollee's fault. The Plan denied your request. The Plan says your benefit maximum has been met for this 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, comprehensive oral evaluation (D0150) is limited to once every 36 months. The record shows that the enrollee received a comprehensive oral evaluation (D0150) on February 13, 2020 and the enrollee's comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) of the spine provided on June 9, 2021.

You asked the Plan to waive the copayment for the MRI. You say that you do not think you should have to pay for an unreadable test. 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 $285 copayment for advanced imaging services such as MRI's. 

You have been asked to pay $197.99, which is less than the $285 copayment for the MRI. The MRI falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 magnetic resonance imaging (MRI) of the spine provided on June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the nail debridement (11721) rendered by the out-of-network (OON) provider on July 2, 2021.  

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the nail debridement (11721) rendered by the out-of-network (OON) provider on  July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home visit for the evaluation and management of an established patient (99349) rendered by the out-of-network (OON) provider on November 3, 2021.  

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the home visit for the evaluation and management of an established patient (99349) rendered by the out-of-network (OON) provider on November 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on October 13, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network 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 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 laboratory services rendered by the out-of-network (OON) provider on October 13, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound you had on November 11, 2020.

You asked the Plan to waive the copayment for the ultrasound. You say that you were never advised that any copayment would apply. You said that you cannot afford this bill. 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 $40 copayment for diagnostic radiology services in an office setting or imaging center. 

You have been asked to pay a $40 copayment for the ultrasound. The ultrasound falls within the diagnostic radiology services in an office setting or imaging center 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 ultrasound you had on November 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic colonoscopy (45378) rendered by the out-of-network (OON) provider on October 7, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the diagnostic colonoscopy (45378) rendered by the out-of-network (OON) provider on October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection, diagnostic or therapeutic agent, paravertebral facet, with image guidance (64495) rendered by the out-of-network (OON) provider on May 14, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the injection, diagnostic or therapeutic agent, paravertebral facet, with image guidance (64495) rendered by the out-of-network (OON) provider on May 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on August 25, 2021.  

You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office or facility for a scheduled  non-urgent visit is not a Medicare covered benefit. 

The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination.   

The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on August 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the paramedic intercept services provided on September 5, 2021.    

You asked the Plan to pay for the paramedic intercept services. You say that you feel you should not have to pay for this because you did not ask for this service. The Plan denied your request. The Plan says medical records confirm paramedic intercept services took place, and no payment can be made as paramedic intercept is not covered. The Plan also says that the Plan confirmed that there is no contract between the two ambulance providers.  

The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York.  

The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided on September 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services (62320) provided on October
18, 2021.
You asked the Plan to pay for code 62320. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the records are insufficient to support payment for these
services.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain
documentation requirements must be met. The documentation must include the legible signature of the
physician or non-physician practitioner responsible for providing the care to the patient. In addition, the
procedure report should clearly document the indications and the medical necessity for the blocks along with
the pre and post percent pain relief achieved immediately post-injection.
The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record
is not signed and there is no notation of the percent of pain relief achieved either before or after the injection.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay
for the pain management services (62320) provided on October 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities (97530) provided on September 21, 2021.
You asked the Plan to pay for the therapeutic activities. You say that you would like this claim to be reprocessed. The Plan denied your request. The Plan says the billed services were not supported.
The Plan must follow Medicare rules. Medicare rules say that the services of an Occupational Therapy Assistant (OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Specifically, the billing provider is a nurse practitioner (NP), and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for the therapeutic activities (97530) provided on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lens enhancements (V2784, V2755, V2750, V2744,
V2799) provided on October 9, 2021.
You asked the Plan to pay for the lens enhancements. You say that these enhancements are necessary and
should not be considered optional in your case. The Plan denied your request. The Plan says lens enhancements
are not covered by your vision benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case.
Though the Plan offers a vision 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 lens
enhancements (V2784, V2755, V2750, V2744, V2799) provided on October 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Zilretta.  You asked the Plan to pre-approve Zilretta. You say that the requested Zilretta is medically necessary. The Plan denied your request. The Plan says the requested Zilretta is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Zilretta. Our reviewer says that the requested Zilretta is not medically necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that repeat Zilretta injections meet Medicare criteria for the enrollee. The efficacy and safety of repeat administration of Zilretta have not been demonstrated.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta.