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

We decided that the Plan does not have to pay for a consultation-diagnostic services (D9310) provided by an
out-of-network provider on February 9, 2021.

You asked the Plan to pay for a consultation-diagnostic services. You say that you feel like this should be
covered by the Plan. The Plan denied your request. The Plan says services must be provided by a participating
provider, unless prior authorization has been obtained.

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. Prior authorization must be obtained if an out-of-network provider is
providing services. Therefore, we decided that the Plan does not have to pay for a consultation-diagnostic
services (D9310) provided by an out-of-network provider on February 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $350 copayment charged for ambulance transport provided on March 5, 2021.
You asked the Plan to waive this copayment. You say that his ambulance service was the result of a severe nosebleed caused by a Covid-19 test. You believe this copayment should be waived because this is related to Covid-19. The Plan denied your request. The Plan says the transport is being covered by the Plan and Medicare; your copayment is a contractual obligation.
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 contract with the Plan clearly says that enrollees must pay $350 copayment for each one-way ambulance transport.
You have to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Medicare is not waiving copayments for services like ambulance transport for services related to Covid-19. Therefore, we decided that the Plan does not have to waive the $350 copayment charged for ambulance transport provided on March 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request.
The Plan says rules for SNF care have 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 that you have stabilized medically and is ready
for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily
basis. You are medically stable and can receive further rehab services at a lower level of care. Although further
rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services
can be provided at a lower level of care than a skilled nursing facility. You do not have any parental
medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any
acute exacerbations of chronic medical problems. Your physical function is at or near her baseline and she can
receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection of diagnostic or therapeutic 
substance into lumbar spinal canal with imaging guidance (62323) provided on May 24, 2021. 
 
You asked the Plan to waive the copayment for a spinal injection using imaging guidance. You say that you 
thought the plan would pay 80% of the cost-share and you do not have the money to pay for this copayment. 
The Plan denied your request. The Plan says the cost-share 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 $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $250 copayment for a spinal injection using imaging guidance. Since this service 
was provided at an ambulatory surgical center, the Outpatient Surgery, Including Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers benefit category was applied to determine your cost-
share. 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 an injection of diagnostic or therapeutic 
substance into lumbar spinal canal with imaging guidance (62323) provided on May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a core buildup including pins (D2950) and prophylaxis (D1110) provided on April 23, 2021.
You asked the Plan to pay for a core buildup including pins and prophylaxis. You say that you do not agree with your responsibility on this claim. You also say you would like the claim to be reprocessed and paid. The Plan denied your request. The Plan says there is no coverage for a core buildup including any pins and prophylaxis.
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 a core buildup including pins (D2950) and prophylaxis (D1110) provided on April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0709) provided by a participating provider on May 11, 2021.

You asked the Plan to pay for intraoral - complete series of radiographic images. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says this is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0709) provided by a participating provider on May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on May 
19, 2021. 
 
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because screening genetic 
tests are not a Medicare-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 tests at issue in this appeal, genetic testing, were requested for screening purposes. Medicare does not 
cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for 
hereditary cardiovascular screening testing provided on May 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), a harness (E2313), 
and electronic connection between wheelchair controller and two or more power seating system motors 
(E2311). 
 
You asked the Plan to pre-approve an expandable controller, a harness, and electronic connection. 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 follows Medicare rules. Medicare rules say that wheelchair accessories are covered when specific 
criteria are met. 
 
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 an expandable controller, a harness, and 
electronic connection. Our reviewer says that the items are not medically necessary. Our physician reviewer 
found the documentation does not reveal that the enrollee requires other types of proportional input  devices 
(e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional 
input devices (e.g., sip and puff, head array, etc.) The enrollee does not need to operate 3 or more powered 
seating actuators through the drive control, a separate display (i.e., for alternate control devices), other 
electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control), or an attendant control. The enrollee's strength and funct ion in the right upper extremity with the 
ability to feed himself supports that the enrollee can control any power options through their own individual 
switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, a harness, and electronic connection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), a 
harness (E2313), and electronic connection between wheelchair controller and two or more power seating 
system motors (E2311).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $225 copayment charged for ambulance transport.  
 
You asked the Plan to waive this copayment. You say that you were treated horribly by the ambulance crew 
and question being required to pay a copayment. The Plan denied your request. The Plan says this copayment is 
a contractual obligation as the Plan has paid its portion of this bill. Your concerns regarding the ambulance 
crew will be handled as a grievance by the Plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan clearly says that you must pay $225 copayment for each one-way ambulance transport. 
This cost sharing is a contractual obligation. Therefore, we decided that the Plan does not have to waive the 
$225 copayment charged for ambulance transport provided on May 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography guidance for placement of radiation therapy fields (77014) provided March 30, 2021 to March 31, 2021.

You asked the Plan to pay for the radiology service. You say that the provider performed the services in question and should be paid accordingly. Please review the attached documents and process for payment per the provider contract. The Plan denied your request. The Plan says the provider has not submitted any clinical to support the medical necessity of the services.

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 find that CPT code 77014 is not supported in the medical record. Specifically clinical records were not submitted to support the medical necessity of the services. The records show the Plan made multiple attempts to obtain the additional records. Based on this information, we decided that Medicare rules for coverage of the radiology service have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography guidance for placement of radiation therapy fields (77014) provided March 30, 2021 to March 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87496, 87498, 87798, 87486, 87541, 87581, 87640) provided on May 27, 2020.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with a correct 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 (87496, 87498, 87798, 87486, 87541, 87581, 87640) provided on May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay and additional amount for the detailed and extensive oral 
evaluation (D0160) and root canal (D3330) provided on April 27, 2021. 
 
You asked the Plan to pay and additional amount for the dental services. You say that you were referred to this 
provider by your oncologist. You say that you do not have time to look around for a doctor that meets the 
expectations of your health plan because this situation is a priority. You also say that you feel these services 
should be covered. The Plan denied your request. The Plan says there is a 20% coinsurance for preventive 
dental services received out o network. The Plan says there is a 50% coinsurance for comprehensive dental 
services received out of network. The Plan also says that the claim was processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed is covered, 
the provider in this case is out of network. Dental services that you receive out of network have a higher cost 
sharing amount. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. 
Therefore, we decided that the Plan does not have to pay and additional amount for the detailed and extensive 
oral evaluation (D0160) and root canal (D3330) provided on April 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 27, 2020.

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 not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in a skilled nursing facility setting
and should have been billed with POS code 32. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Volara System. 
 
You asked the Plan to pre-approve the Volara System. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 the Volara System. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a review of the current medical literature indicates that this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use as reported in nationally recognized peer-reviewed medical literature. The review has determined that the 
items/services at issue in this case are not medically reasonable or 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 Volara System have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Volara System.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for mechanical traction (97012) and manual electrical stimulation (97032) provided May 14, 2021 to June 2, 2021.
You asked the Plan to pay for the chiropractic services. You say that you would rather have periodic chiropractic care than look at the possibility of back surgery. Since this chiropractic care was suggested by your doctor, you feel the claim should be covered. The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for mechanical traction (97012) and manual electrical stimulation (97032) provided May 14, 2021 to June 2, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says rules for SNF care have 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 member has stabilized medically and is 
ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy 
services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. 
Although further rehab services would be appropriate to improve function, as a practical matter, the 
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The member 
does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is 
medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or 
near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled 
rehab services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the vertical bitewings (D0277). We decided that the Plan does not have
to pay for the panoramic x-ray (D0330) and preventive procedure (D1999).

You asked the Plan to pay for the vertical bitewings (D0277), panoramic x-ray (D0330), and preventive
procedure (D1999). You say that you contacted the Plan and checked with the provider prior to receiving these
services and were advised the treating provider was in-network. You also say that you would like to be
reimbursed because everything shows that the treating provider was in-network and should have been covered
by your insurance. The Plan says that these services are not covered expenses under your Dental plan.

We decided that the Plan has to pay for the vertical bitewings (D0277).

The Plan follows Medicare rules. Medicare rules say that the health plan must provide you with a clear and
accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under
your plan contract including applicable conditions and limitations and any other conditions associated with the
use or receipt of the benefits.

The record shows that you received vertical bitewings. The 2020 Evidence of Coverage (EOC) says bitewing
x-rays are a covered benefit and are limited to one set per calendar year. The EOC does not specifically state
which types of bitewing x-rays are covered, nor does the EOC list specific codes of covered dental services.
You reasonably believed the vertical bitewing x-rays would be covered because bitewing x-rays are listed as a
covered benefit. The Plan has also indicated that you were misinformed that the treating provider was in-network.
Therefore, we decided that the Plan has to pay for the vertical bitewings (D0277).

We also decided that the Plan does not have to pay for the panoramic x-ray (D0330) and preventive
procedure (D1999).

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
panoramic x-ray (D0330) and preventive procedure (D1999).

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.