Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214) radiologic examination, chest (71046) bone density scan (77080) provided on July 9, 2020 to July 24, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the diagnostic outpatient visits. You say that you would like help to pay these days. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 outpatient office visit (99214) radiologic examination, chest (71046) bone density scan (77080) provided on July 9, 2020 to July 24, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 13, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that you would like this claim reprocessed. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

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 May 13, 2021, 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 core build up (D2950) and root canal (D3330) provided from October 26, 2020, to November 9, 2020.

You asked the Plan to pay for the dental services. You say that you, the dental office, and your insurance broker have contacted your plan many times. You say that conflicting information has been given. You say that prior to the procedure you were advised that a percentage would be covered. You also say that you were advised since you had not had a root canal previously, you had lost that portion of coverage. The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan says that root canal is not listed as a covered service either.

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 core build up and root canal are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up (D2950) and root canal (D3330) provided from October 26, 2020, to November 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) provided on October 20, 2020.

You asked the Plan to pay for the crown. You say that you never received a crown while you have been under this insurance. You also say that the crown was erroneously listed twice on the claim form. The Plan denied your request. The Plan says the annual maximum benefit provision of your benefit plan was reached for this claim.

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 covers up to $1,000 every year for combined in and out-of-network non-Medicare covered comprehensive dental services. The record shows that you met the annual maximum benefit on September 30, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the crown (D2740) provided on October 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for oral exam (D0120) and cleaning (D1110) provided on September 9, 2021.

You asked the Plan to reimburse you for the dental services. You say that the claim was for an annual dental cleaning checkup. You say that a licensed dentist in the state of Maine denied the non-Medicare services on page 66 of the Evidence of Coverage. You also say that you believe this is illogical to exclude non-routine dental care from coverage. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made to a provider that 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 dental services performed by a provider that has opted out of Medicare are not among those covered under this benefit. This benefit includes dental services performed by a licensed provider in the United States that is not on the opt out list. Therefore, we decided that the Plan does not have to reimburse you for oral exam (D0120) and cleaning (D1110) provided on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (98941) provided on November 3, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the chiropractic services. You say that you have been visiting this chiropractor for a long time and have never had a claim denied and never had to have an approval. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 chiropractic services (98941) provided on November 3, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on
September 20, 2021.
You asked the Plan to waive the copayment for these services. You say that the enrollee was seen by the nurse
practitioner. The Plan denied your request. The Plan says the copayment was applied 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 $30
copayment for each Medicare-covered specialist visit.
Review of the file shows that the enrollee received specialist services on September 20, 2021. The enrollee has
been asked to pay a $30 copayment for these services. These services fall within the Medicare-covered
specialist visit benefit category. This means that the enrollee has been asked to pay the correct amount based on
the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when they
enrolled in the Plan. The copayment applies for services received in a specialist's office, regardless of whether
the services are from a physician or nurse practitioner. Therefore, we decided that the Plan does not have to
waive the copayment for the specialist services rendered on September 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne testing (0037U) provided February 16,
2021.
You asked the Plan to pay for the FoundationOne testing. You say that you would like reconsideration because
this testing was medically necessary. The Plan denied your request. The Plan says the documentation and
medical records do not indicate the member has "either recurrent, relapsed, refractory, metastatic, or advanced
stage II or IV cancer.
The Plan follows Medicare rules. Medicare rules say that services that are not medically necessary are 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 pay for the FoundationOne testing. Our reviewer
says that this testing is not medically reasonable or necessary. Our physician reviewer found stage I non-small-
cell lung cancer does not require chemo, thus a look for actionable mutations is not reasonable and necessary.
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 FoundationOne testing have not been met. Therefore, we decided that the
Plan does not have to pay for the FoundationOne testing (0037U) provided February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete dentures (D5120, D5110), provided on October
11, 2021, by an out-of-network provider.
You asked the Plan to pay for the complete dentures. You say that the service was medically necessary and
should be covered. The Plan denied your request. The Plan says you received these services through an out-of-
network 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
complete dentures (D5120, D5110), provided on October 11, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Chiropractic manipulative treatment (98941) and supplies
and materials (99070) provided on January 27, 2021 to September 9, 2021 by an out-of-state provider.
You asked the Plan to pay for the chiropractic services. You say that you are asking to be allowed help with
coverage for 12 total visits. The Plan denied your request. The Plan says enrollee's must receive their medical
services from an in-network provider with the exception being urgent or emergent services. Non-emergent
services with non-contracted providers require prior authorization before services being rendered.
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. CPT code 99070 is not a Medicare covered benefit. 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
Chiropractic manipulative treatment (98941) and supplies and materials (99070) provided on January 27, 2021
to September 9, 2021 by an out-of-state provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a biopsy (88305) provided on August 17, 2021, by an out-of-
network (OON) provider.
You asked the Plan to pay for a biopsy. You say that you were not aware you needed authorizations or
referrals. The Plan denied your request. The Plan says out-of-network services require authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for a biopsy (88305) provided on August 17, 2021, by
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies and clinical staff time to perform safety
protocols (99072) chiropractic manipulation of the extra-spinal regions (98943) mechanical traction (97012)
provided September 2, 2021.
You asked the Plan to pay for additional supplies and clinical staff time. You say that the medical records
provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the
service is considered incidental to the total episode of care. The service is not covered when billed by a
chiropractor. The services were previously billed by and paid to another provider for this service.
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 99072
is a column II code to column I code G0283. Specifically, CPT code 99072 has a status indicator of B and is
considered bundled and not separately payable. G0283 was billed and paid to another provider for the same
date of service. For CPT codes 98943 and 97012, these services are not covered when billed by a chiropractor.
Only manual manipulation of the spine to correct subluxation is covered by the Plan. Based on the claim
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to
pay for additional supplies and clinical staff time to perform safety protocols (99072) chiropractic manipulation
of the extra-spinal regions (98943) mechanical traction (97012) provided September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a primary care physician office visit received on June 28, 2021.

You asked the Plan to waive the copayment for the services. You say that the initial correspondence stated a $0 copayment. The Plan denied your request. The Plan says cost-sharing is a contractual obligation under the plan and cannot be waived.

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 $15 copayment for primary care physician services. 

You have been asked to pay a $15 copayment for the services. The services fall within the primary care physician services benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for a primary care physician office visit received on June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for DecisionDx-Squamous cell carcinoma (SCC) testing
provided on June 18, 2021.
You asked the Plan to pay for DecisionDx-SCC testing. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 DecisionDx-SCC testing 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
DecisionDx-Squamous cell carcinoma (SCC) testing provided on June 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient surgery provided from August
27, 2021, to October 22, 2021.
You asked the Plan to waive the copayments for outpatient surgery. You say that it is not appropriate to charge
a $200 copayment for each visit. The Plan denied your request. The Plan says the proper copayments were
applied for the dates of service.
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 $200
copayment for each Medicare-covered outpatient surgical service. For the dates of service of August 27, 2021,
September 3, 2021, September 10, 2021, September 17, 2021, September 24, 2021, and October 1, 2021, there
was a total copayment charge of $1,200 ($200 each visit copayment x 6 visits). On August 31, 2021, the total
amount charge was only $126.66 which is less than the copayment amount of $200. Therefore, only $126.66
was charged for the copayment. There was no copayment charged for October 8, 2021, and October 22, 2021.
The total amount charged for the copayments of for the dates of service was $1,326.66 ($1,200 copayment +
$126.66 copayment).
You have been asked to pay a $1,326.66 copayment for outpatient surgery. Outpatient surgery falls within the
Outpatient hospital 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 outpatient
surgery provided from August 27, 2021, to October 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the seat elevator (E2300).
You asked the Plan to pay for the seat elevator. You say that you need this item. The Plan denied your request.
The Plan says this item does not primarily serve a medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pay for the seat elevator (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210), limited oral evaluation (D0140), and periapical x-ray (D0220) provided on September 15, 2021.

You asked the Plan to pay for the dental services. You say that you were advised the services would be covered. The Plan denied your request. The Plan says extraction is not listed as a covered service. The Plan says that limited oral evaluation is not listed as a covered service. The Plan also says that periapical x-ray is not listed as a covered service either.

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 extraction, limited oral evaluation, and periapical x-ray are not among those covered under this benefit. Additionally, there is no record that you contacted the Plan to verify benefits prior to the date of service. Therefore, we decided that the Plan does not have to pay for the extraction (D7210), limited oral evaluation (D0140), and periapical x-ray (D0220) provided on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management office visit provided on August 6, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the OON pain management evaluation. You say that the medical records show this visit was reasonable and necessary. The Plan denied your request. The Plan says these services were provided by an OON provider without authorization being requested. Non-emergency services from OON providers are only covered when pre-approved.

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 pain management office visit provided on August 6, 2021, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit and the electrocardiogram provided on October 7, 2020.

You asked the Plan to pay for the emergency department visit and the electrocardiogram. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the claim was filed untimely.

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 the emergency department visit and the electrocardiogram was not filed until October 12, 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 the emergency department visit and the electrocardiogram provided on October 7, 2020.