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

We decided that the Plan does not have to pre-approve benign skin growth removal.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not document bleeding, itching, or pain. 

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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that the enrollee has an epidermal inclusion cyst. The record provided does not indicate the presence of any of the enumerated conditions required for coverage to be available for treatment under the local coverage determination. The elements of the coverage criteria are not satisfied.

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve benign skin growth removal.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay amounts for the 8 specialist office visits and stress test provided from April 21, 2022, to April 26, 2022, in the outpatient hospital office.

You asked the Plan to waive the copay amounts for the outpatient services. You say that you are being billed $40 copays for each doctor that came in your room while you were in the hospital. You say that you were admitted to the hospital. You say that you do not know why this was billed as observation instead of inpatient. You also say that you are being billed 2 times. The Plan denied your request. The Plan says the cost sharing was charged correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for specialist visits and a $100 copayment for advanced imaging services, including stress test, for Outpatient Hospital Services. 

You have been asked to pay a $40 copayment for each outpatient specialist visit and a $35.65 copayment for the advanced imaging. These services fall within the Outpatient Hospital Services benefit category. This means that you have been asked to pay the correct amounts based on your contract with the Plan. These cost sharing are contractual obligations you agreed to pay when you enrolled in the Plan. The record shows that you were seen separately by a cardiologist and a nephrologist each day, thus accounting for two specialist visits each day. The record shows that the allowed amount for the stress test ($35.65) was less than the copayment amount ($100), thus you are only responsible for the allowed amount for this service. Additionally, the record indicates that the services were provided in an outpatient setting and thus you were billed correctly. Therefore, we decided that the Plan does not have to waive the copay amounts for the 8 specialist office visits and stress test provided from April 21, 2022, to April 26, 2022, in the outpatient hospital office.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0364) and problem focused limited oral evaluation (D0140) provided on June 23, 2022. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation and problem focused limited oral 
evaluation. You say that you needed these emergency dental services that were rendered by an out-of-network 
dentist because you would have had to drive more than 70 miles to find a dentist that accepts your plan. The 
Plan denied your request. The Plan says the cone beam CT capture and interpretation is not covered under your 
plan. The Plan also says that the problem focused limited oral evaluation exceeds the frequency limitation in 
your benefit plan. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the cone beam CT capture and 
interpretation (D0364) is not among those covered under this benefit. The contract says that problem focused 
limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received 
another problem focused limited oral evaluation (D0140) on June 23, 2022, with another provider and your 
problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the 
Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364) 
and problem focused limited oral evaluation (D0140) provided on June 23, 2022.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the SPECT provided on June 16, 2022.

You asked the Plan to pay for the (SPECT). You say that the denial of the rendered services should be reconsidered and accepted. The Plan denied your request. The Plan says that the service was denied for no prior authorization.

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.

The enrollee was referred for the (SPECT) by an in-network contract provider. Under Medicare rules, this means the (SPECT) is considered approved by the plan. Therefore, we decided that the Plan has to pay for a single photon emission computed tomography (SPECT) provided on June 16, 2022. 

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 86077 billed for date of service May 3, 2022.

You asked the Plan to pay for procedure code 86077. You say that the services at issue were billed correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 86077 billed for date of service May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the contact lenses (V2520) and evaluation (S0592) provided
on June 21, 2022.

You asked the Plan to pay for the contact lenses and evaluation. You say that your prescription changed, and
you believed you needed another exam. You also say that you have never had your insurance say you are only
allowed one exam every two years, and that one year was standard for vision, nor did you receive a notice of
change in benefits. The Plan denied your request. The Plan says this exceeds the maximum benefit allowed.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services every two calendar years.

We looked at the file and the Plan's rules. The record shows that you last received contact lenses on June 23,
2021, and your eyeglass frames and contact lenses benefit has been exhausted. Based on this information, we
decided that the Plan's rules for coverage of the contact lenses and evaluation have not been met. Therefore, we
decided that the
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), the consultation 
(D9310), and the cone beam computed tomography (CT) capture and interpretation (D0364) provided by an 
out-of-network provider on July 21, 2022. 
 
You asked the Plan to pay for the consultation (D9310) and the cone beam CT capture and interpretation 
(D0364). You say that you were approved for a root canal, and you had no way of knowing that a root canal 
was not needed until you received the x-rays. The Plan denied your request. The Plan says the services are not 
covered benefits. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 first 
intraoral periapical x-ray (D0220), the consultation (D9310), and the cone beam computed tomography (CT) 
capture and interpretation (D0364) provided by an out-of-network provider on July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for paring or cutting of benign hyperkeratotic lesion (11056) provided on June 15, 2022.

You asked the Plan to pay for the routine foot care. You say that you feel this is a necessary procedure for you to function. You also say that you are not able to walk unless you have this done. The Plan denied your request. The Plan says the routine foot care is not covered.

The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. 

Records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the routine foot care have not been met. Therefore, we decided that the Plan does not have to pay for paring or cutting of benign hyperkeratotic lesion (11056) provided on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5212) 
 
You asked the Plan to pre-approve the dental services. You say that you need a new pair of dentures because of 
the wear and tear. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of April 26, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5212)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) provided by 
an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that this is your long-time dentist. You say that 
you would like to continue to see this dentist. The Plan denied your request. The Plan says dental services from 
an out-of-network provider are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation (D0150) provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on June 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed this exam in order to get three teeth 
pulled. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 6, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete mandibular denture (D5120) provided by a 
participating provider on January 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you cannot eat without new dentures. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 25, 2020. 
Therefore, we decided that the Plan does not have to pay for a complete mandibular denture (D5120) provided 
by a participating provider on January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 30, 2020. 
Therefore, we decided that the Plan does not have to pay for the dental services on June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 
28, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like to appeal the 
Plan's decision. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 13, 2020. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral evaluation (D0150) provided on June 23, 2022. 
 
You asked the Plan to pre-approve the dental services. You say that this procedure is covered by the dental 
Plan. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of October 23, 2020. 
Therefore, we decided that the Plan does not have to pre-approve an oral evaluation (D0150) provided on June 
23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper partial denture (D5213) and the extractions 
(D7140x6) provided on February 28, 2022, and May 25, 2022. 
 
You asked the Plan to pay for the upper partial denture (D5213) and the extractions (D7140x6). You say that 
you would like to be reimbursed more for the remaining charges. You say you need help with the financial 
burden. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 upper 
partial denture (D5213) and the extractions (D7140x6) provided on February 28, 2022, and May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture (D5214) provided on June 22, 
2022. 
 
You asked the Plan to pay for the mandibular partial denture. You say that you thought the Plan would pay for 
half of the denture. The Plan denied your request. The Plan says this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
mandibular partial denture (D5214) provided on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110) 
and oral hygiene instructions (D1330) provided on May 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the periodic oral evaluation (D0120), prophylaxis (D1110) and oral hygiene instructions (D1330) 
provided on May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the spinal manipulation (98941) provided on June 8, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for the chiropractic care. You say that the service should be covered. The Plan denied your request. The Plan says authorization was not obtained before the service was rendered to the enrollee.

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 spinal manipulation (98941) provided on June 8, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on June 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was for a general cleaning and you believe 
this is covered by the Plan once a year. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 14, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on June 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 31, 2022, through 
April 29, 2022. 
 
You asked the Plan to pay for home health services. You say that the NOA was submitted per Medicare 
guidelines and proof is attached. The Plan denied your request. The Plan says the NOA is required to process 
the final claim. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services under a plan of care are 
paid based on a 30-day period of care. HHAs submit an NOA at the beginning of an admission and then submit 
one claim for each 30-day period of care.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the NOA was not submitted. Therefore, we 
decided that the Plan does not have to pay for home health services provided from March 31, 2022, through 
April 29, 2022.