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

We decided that the Plan does not have to pay for the lower partial denture with a flexible base (D5226) provided on April 15, 2021.
You asked the Plan to pay for the lower partial denture. You say that you were not able to be seen by a network dentist for months and felt this dentist would be able to provide covered services. The Plan denied your request. The Plan says on review, all covered services provided by this dentist were approved. The flex base partial denture remains denied since this is not covered by your 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 lower partial denture with a flexible base (D5226) provided on April 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have narrowing of the spine (spinal stenosis) of the low back. The Food and Drug Administration (FDA) indicates the use of the Superion spacer for spinal stenosis at no more than two levels. The records show that you have multiple degrees of stenosis; therefore, the services are not medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the acute inpatient hospital care and
skilled nursing facility (SNF) care provided from December 16, 2020, to January 1, 2021.
You asked the Plan to waive the copayments for the inpatient and SNF care. You say that you say that you
should not be responsible for the copayments as they are related to the coronavirus. The Plan denied your
request. The Plan says the copayments were applied correctly according to your plan benefits.
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 $160
copay per day for days 1 to 7 for inpatient hospital care. You contract with the Plan also says that you must pay
$178 copay per day for days 21 to 100 for SNF care.
You have been asked to pay $160 copay per day for days 1 to 7, or $1,120, for the inpatient care. The acute
inpatient care falls within the inpatient hospital care benefit category. The file shows that you tested negative
for the coronavirus at the beginning of the inpatient admission. The waiver clearly says that the Plan does not
waive cost sharing for treatment of ongoing complications stemming from a previous coronavirus diagnosis.
This means that you have been asked to pay the correct amount based on your contract with the Plan. You have
also been asked to pay $178 copay per day for days 21 to 22 for the SNF care. The SNF care falls within the
SNF care benefit category. The file shows that you were previously enrolled in a SNF for care prior to your
inpatient stay. The Evidence of Coverage states there must be 60 days between stays for the benefit period to
restart. The file shows there was 7 days between stays. This means you have been asked to pay the correct
amount based on your contract with the Plan. These cost sharing amounts are 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 acute inpatient hospital care and skilled nursing facility (SNF) care provided from
December 16, 2020, to January 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent testing by polymerase chain reaction (PCR) for respiratory pathogens provided on August 4, 2020, billed with codes 87496, 87498, 87631, 87798, 87486, 87541, 87581, and 87640.
You asked the Plan to pay for the respiratory pathogen testing by PCR as billed. You say that this is medically necessary and should be paid. The Plan denied your request. The Plan says this is billed with an inappropriate POS code.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the respiratory pathogen testing by PCR as billed have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent testing by polymerase chain reaction (PCR) for respiratory pathogens provided on August 4, 2020, billed with codes 87496, 87498, 87631, 87798, 87486, 87541, 87581, and 87640.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15-minute increment (D9223), and therapeutic parenteral drugs, two or more administrations, different medications (D9612) provided May 26, 2021.
You asked the Plan to pay for the sedation/anesthesia and therapeutic parenteral drugs. You say that you had your wisdom tooth extracted and it was necessary and recommended by the oral surgeon to have the sedation. The Plan denied your request. The Plan says these services are not covered under your benefits.
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 deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15-minute increment (D9223), and therapeutic parenteral drugs, two or more administrations, different medications (D9612) provided May 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (R0070, 73562, Q0092) provided on April 7, 2021.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not emergent or pre-authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 radiology services (R0070, 73562, Q0092) provided on April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the protective restoration (D2940) provided May 13, 2021.
You asked the Plan to pay for the protective restoration. You say that you feel this service should be covered at 50%. The Plan denied your request. The Plan says this service is not covered under your benefits.
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 protective restoration (D2940) provided May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) rendered by the out-of-network (OON) provider on October 14, 2020.
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 unlisted molecular pathology procedure (81479) rendered by the out-of-network (OON) provider on October 14, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for an eye refraction (92015), and ophthalmic biometry
(92136 x2) provided on May 18, 2021.
You asked the Plan to hold you harmless for an eye refraction, and ophthalmic biometry. You say that the
services should be covered, and you shouldn't have to pay anything. The Plan denied your request. The Plan
says that the provider is out-of-network.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
You were referred for an eye refraction, and ophthalmic biometry by a contract provider. The file does not
show that the Plan provided notice that an eye refraction, and ophthalmic biometry would not be covered.
Under Medicare rules, this means an eye refraction, and ophthalmic biometry is considered approved by the
Plan. Specifically, while you did not receive services from the Plan's supplemental vision benefits vendor, the
services were received from a Plan contracted provider. The Plan contracted provider did not give notice that
services would not be covered. The services at issue are examples of services that are normally not covered but
can be covered under certain circumstances. The EOC is therefore, not adequate notice of non-coverage in this
case. Therefore, we decided that the Plan has to hold you harmless for an eye refraction (92015), and
ophthalmic biometry (92136 x2) provided on May 18, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexcom G6 Receiver Device (CPT code K0554), for 
the enrollee. 
 
You asked the Plan to pre-approve the device. You say that the enrollee has diabetes and are not on insulin. 
The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee is not currently treated 
with insulin. 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 Dexcom G6 Receiver Device (CPT 
code K0554), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided from February 7, 2018 to April 4, 2018.
You asked the Plan to pay for these services. You say that the Plan should pay for these services. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for out of network physician services provided from February 7, 2018 to April 4, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair glide purchased April 21, 2021.
You asked the Plan to pay for a stair glide. You say that a stair glide or stair lift was medically necessary. The Plan denied your request. The Plan says stair glide or stair lift equipment is not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a stair glide purchased April 21, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for moderate sedation services (99153) provided on February 9, 2021.

You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration because the member had multiple exams on the same date of service. The Plan denied your request. The Plan says that 7 units of CPT code 99153 have been processed and paid.

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. Specifically, the Plan has not forwarded any evidence that a duplicate claim has been submitted. There is no evidence that CPT code 99153 has been paid by the Plan. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for moderate sedation services (99153) provided on February 9, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (procedure code 76942) provided to the
enrollee on April 21, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. 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 CPT code.
In this case, the CPT Code Manual definition of code 76942 is "Ultrasonic guidance for needle placement (eg,
biopsy, aspiration, injection, localization device), imaging supervision and interpretation."
We find that CPT code 76942 is not supported in the medical record. Specifically, this code cannot be paid
separately from CPT 78278 without an appropriate modifier on the claim. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan
does not have to pay for imaging services (procedure code 76942) provided to the enrollee on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Eylea injection you received on June 8, 2021.
You asked the Plan to waive the coinsurance for the Eylea injection. You say that you had this same procedure before and didn't have to pay anything. The Plan denied your request. The Plan says it initially processed this claim incorrectly. You are now only responsible for 20% coinsurance for the injected drugs.
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 Medicare Part B drugs. You have been asked to pay 20% coinsurance for the Eylea injection. The Eylea injection falls within the Medicare Part B drugs benefit category. This coinsurance applies regardless of what you may have been charged in the past. 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 the Eylea injection you received on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral exam (D0140) panoramic x-ray (D0330) and surgical removal of erupted tooth (D7210) invalid procedure (D0001) provided January 12, 2021 to February 8, 2021.
You asked the Plan to pay for the dental services. You say that the 2021 Annual Report of Changes produced by the Plan referred to out of network providers. The extraction performed appears to qualify for major services benefits. The Plan denied your request. The Plan says the services were performed by a provider who has chosen to opt out of Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program.
Therefore, we decided that the Plan does not have to pay for limited oral exam (D0140) panoramic x-ray (D0330) and surgical removal of erupted tooth (D7210) invalid procedure (D0001) provided January 12, 2021 to February 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a chemotherapeutic regimen administered on April 27 to May 11, 2021.
You asked the Plan to waive the coinsurance for a chemotherapeutic regimen. You say that the charges at issue are too expensive. The Plan denied your request. The Plan says the correct coinsurance was applied.
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 Part B drugs. You have been asked to pay $633.42 per date of service, or 20% of the Medicare-allowed charge of $3,167.10, for a chemotherapeutic regimen. A chemotherapeutic regimen falls within the "Part B drugs" 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 a chemotherapeutic regimen administered on April 27 to May 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for Sanexas neoGen-series therapy (electrical cell stimulation), Vasopneumatic device therapy, and associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend provided on December 4, 2020.
You asked the Plan to pay for Sanexas neoGen-series therapy (electrical cell stimulation), Vasopneumatic device therapy, and associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend. The Plan denied your request. The Plan says the services do not meet the Medicare guidance criteria.
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. You can find this information in Title 42 CFR Section 410.60. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Sanexas neoGen-series therapy (electrical cell stimulation), Vasopneumatic deice therapy, and associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend have not been met. Therefore, we decided that the Plan does not have to pay for Sanexas neoGen-series therapy (electrical cell stimulation),Vasopneumatic device therapy, and associated codes for the subcutaneous injection of FDA Nutri-Pharmaceutical blend provided on December 4, 2020.