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

We decided that the Plan does not have to pay for laboratory services (82274, 82656, 83520, 83631, 87338) provided on September 8, 2020.
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied your request. The Plan says this was billed with an incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met.
Therefore, we decided that the Plan does not have to pay for laboratory services (82274, 82656, 83520, 83631, 87338) provided on September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment supported crown (D6058) provided on April 5, 2021.
You asked the Plan to pay for the custom fabricated abutment. You say that the services were medically necessary. You also say that that your dentist advised that the treatment done to tooth # 20 was the best option and was dentally necessary. The Plan denied your request. The Plan says custom fabricated abutment is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the custom fabricated abutment is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment supported crown (D6058) provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth services (99421) provided on January 23, 2021.
You asked the Plan to pay for the telehealth services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not pre-authorized. There were network providers available.
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 telehealth services (99421) provided on January 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the amalgam - three surfaces, primary or permanent (D2160) provided February 11, 2021, the resin-based composite - one surface, anterior (D2330) and resin-based composite - three surfaces, anterior (D2332) provided March 9, 2021, and the amalgam - two surfaces, primary or permanent (D2150), provided April 27, 2021
You asked the Plan to provide additional payment for the amalgams and resin-based composites. You say that you would like the Plan to pay more covered for these services. The Plan denied your request. The Plan says the Plan has covered one composite and one amalgam according to your OON benefits. The remaining composites and amalgam are not covered because they exceed the frequency limit for these services.
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 two amalgams and/or resin-based composites per calendar year. We looked at the file and Medicare rules. The Plan provided documentation showing that the Plan paid for 45% of the allowed amount for one amalgam and one composite. You were responsible for 55% of the cost of this amalgam and composite as well as the difference between the Plan's allowed amount and the total cost billed by the OON provider. Based on this information, we determined that the Plan's frequency limit for coverage of the amalgams and resin-based composites has been met and the remaining composites and amalgam are not covered. Therefore, we decided that the Plan does not have to provide additional payment for the amalgam - three surfaces, primary or permanent (D2160) provided February 11, 2021, the resin-based composite - one surface, anterior (D2330) and resin-based composite - three surfaces, anterior (D2332) provided March 9, 2021, and the amalgam - two surfaces, primary or permanent (D2150), provided April 27, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drug provided on May 27, 2021.
You asked the Plan to pay for the self-administered drug. You say that the term self-given drug to you refers to
an over the counter drug. You also say that you do not believe you are able to buy Nitroglycerin over the
counter. The Plan denied your request. The Plan says self-administered drugs are not included in Part A or Part
B coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drug
provided on May 27, 2021.
Benefits for the self-administered drug may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $350 copayment charged for nuclear medicine provided on May 6, 2021.
You asked the Plan to waive this copayment. You say that you were unhappy with the staff who treated you and should not have to pay this copayment. The Plan denied your request. The Plan says this copayment was charged based on the Plan contract agreement.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for nuclear medicine.
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 $350 copayment charged for nuclear medicine provided on May 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 12, 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 services rendered by non-participating providers require 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 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 laboratory services provided to the enrollee on April 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. At this point, the enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the AlloSure testing provided on December 29, 2020 by a non-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-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 requested provider in this case is not a network provider with the Plan. The referring provider 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 AlloSure testing provided on December 29, 2020 by a non-network provider.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance service, advanced life support, emergency transport, level 1
provided on May 27, 2021.
You asked the Plan to pay for ambulance service, advanced life support, emergency transport, level 1. You say
that the ambulance transport was medically necessary. The Plan denied your request. The Plan says that the
ambulance transport was not medically necessary.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. The Plan follows the same rules.
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 ambulance service, advanced life support,
emergency transport, level 1. Our reviewer says that the ambulance transport was medically necessary. Our
physician reviewer found the enrollee is a 58-year-old female with diabetes, hypertension, morbid obesity,
atrial fibrillation and cardiovascular disease, presenting symptoms of racing heart and weakness to the point
that 911 was called would meet a prudent layperson's criteria for emergency care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of ambulance service, advanced life support, emergency transport, level 1 have
been met. Therefore, we decided that the Plan has to pay for ambulance service, advanced life support,
emergency transport, level 1 (A0427, A0425) provided on May 27, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage, per statute mile (A0425) provided April 10, 2021.
You asked the Plan to waive the copayment for the emergency ambulance transport and services. You say that you cannot afford the copayment and would like the Plan to cover it. 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 $260 copayment for each one-way Medicare-covered ground ambulance trip.
You have been asked to pay a $260 copayment for the emergency ambulance transport and services. This transport falls within the Ambulance 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 the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage, per statute mile (A0425) provided April 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the 20% coinsurance charged for durable medical equipment and supplies provided on April 7, 2021.
You asked the Plan to waive this coinsurance. You say that you do not agree with the $69.98 coinsurance. The Plan denied your request. The Plan says this coinsurance was applied based on the Plan contract agreement.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The Plan contract says that durable medical equipment has a 20% coinsurance. You have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation you agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 20% coinsurance charged for durable medical equipment and supplies provided on April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic image (D0350) and oral hygiene instructions (D1330) provided on May 20, 2021.
You asked the Plan to pay for the 2D oral/facial photographic image and oral hygiene instructions. You say that you checked the provider's name on the website before and after the services were provided. You also say that the Plan verified that this provider was in-network and coverage should be provided for all services. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan. The Plan also says that they were unable to locate any calls from you or the provider in regards to dental services.
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 2D oral/facial photographic image (D0350) and oral hygiene instructions (D1330) provided on May 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the transport chair, adult size, patient weight capacity up to and including 300 pounds (E1038) provided on March 20, 2021 by an out-of-network (OON) durable medical equipment provider.
You asked the Plan to pay for the transport chair. You say that you received a stair lift that you paid out of pocket for and is requesting reimbursement. 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 transport chair, adult size, patient weight capacity up to and including 300 pounds (E1038) provided on March 20, 2021 by an out-of-network (OON) durable medical equipment provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on April 13, 2021.
You asked the Plan to pay for physical therapy services. You say that the code submitted is valid and correctly identifies the service rendered. You say that the claim should be considered for reimbursement. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the billed services.
The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Specifically, the billing provider is a physician assistant. As such, PT services cannot be paid incident to this provider's professional services. Additionally, the record does not include the rendering providers credentials, so we are unable to verify the billed services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on April 13, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the preventive procedure (D4910). We decided that the Plan does not
have to pay for the preventive procedure (D1999), custom fabricated abutment (D6057), and implant supported
porcelain/ceramic crown (D6065).
You asked the Plan to pay for the preventive procedure, custom fabricated abutment, implant supported
porcelain/ceramic crown, and periodontal maintenance. You say that you have had at least 4 periodontal
surgeries. The Plan says that the preventive procedure, custom fabricated abutment, and implant supported
porcelain/ceramic crown are not covered benefits under your dental plan. The Plan also says that you have no
history of periodontal scaling or periodontal surgery in order for the periodontal maintenance to be covered.
We decided that the Plan has to pay for the periodontal maintenance (D4910).
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not provide any medical records to show that you do not have a
past history of periodontal scaling or periodontal surgery. You stated that you have had at least four periodontal
surgeries. This service was also rendered by an in-network provider, and it is the Plan's responsibility to obtain
records from their providers. You reasonably believed this service would be covered because the contract lists
periodontal maintenance (D4910) as a covered service. Therefore, we decided that the Plan has to pay for the
periodontal maintenance (D4910).
We also decided that the Plan does not have to pay for the preventive procedure (D1999), custom
fabricated abutment (D6057), and implant supported porcelain/ceramic crown (D6065).
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 preventive procedure (D1999),
custom fabricated abutment (D6057), and implant supported porcelain/ceramic crown (D6065) are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the preventive
procedure (D1999), custom fabricated abutment (D6057), and implant supported porcelain/ceramic crown
(D6065).
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 pay for a pneumatic compression device (E0676).
You asked the Plan to pay for a pneumatic compression device. You say that the physician prescribed this device because they felt it was necessary for the medical safety of the enrollee. You feel that you should be compensated for the services which was received. The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. The enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).