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

We decided that the Plan does not have to pre-approve the self-administered drugs provided from March 10, 2021, to March 13, 2021.
You asked the Plan to pre-approve the self-administered drugs. You say that these services were medically necessary. You also say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says coverage is not offered for this type of service.
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 pre-approve the self-administered drugs provided from March 10, 2021, to March 13, 2021.
Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364) provided on June 1, 2021.
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that this procedure was necessary for the dentist to review prior to work being started. 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 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 cone beam CT capture and interpretation (D0364) provided on June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on December 30, 2020.
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 Medicare denies
coverage for all cardiovascular risk assessment panels.
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 test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover
this test for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic testing
provided on December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive procedure (D9999) provided on March 9, 2021.
You asked the Plan to pay for the adjunctive procedure. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 adjunctive procedure (D9999) provided on March 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the peridex-oral rinse (D0001) and prophylaxis (D1110) provided on March 22, 2021 by an OON provider.
You asked the Plan to pay for the peridex-oral rinse and prophylaxis. You say that when you purchased this plan you were told that one dental cleaning was covered annually. The Plan denied your request. The Plan says there is not coverage for peridex-oral rinse. The Plan also says that a prophylaxis is covered at 50% when rendered OON, and you may pay more when the service is received OON.
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 peridex-oral rinse is not among
those covered under this benefit. The contract says that you are responsible for a 50% coinsurance plus the
difference between the billed amount and allowed amount when a prophylaxis is received OON. The Plan also
says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.
Therefore, we decided that the Plan does not have to pay for the peridex-oral rinse (D0001) and prophylaxis
(D1110) provided on March 22, 2021 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the intravenous infusion provided on March 3, 2021.
You asked the Plan to reduce the copayment for the intravenous infusion. You say that your Evidence of Coverage says it should be billed under "Diagnostic test and procedures" with a $25 copayment. You say that this was not an outpatient hospital and an incorrect charge is very overwhelming. The Plan denied your request. The Plan says the copayment 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 $200
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including
but not limited to hospital or other facility charges and physician or surgical charges.
You have been asked to pay a $200 copayment for the intravenous infusion. The intravenous infusion falls
within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and
Ambulatory Surgical Centers" benefit category. The records show the intravenous infusion was billed by the
hospital. 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 reduce the copayment for the intravenous infusion provided on March 3,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of multi-layer compression system coded 29851 provided on April 14, 2021.
You asked the Plan to pay for the application of multi-layer compression system. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 29851 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 the application of multi-layer compression system have not been met. Therefore, we decided that the Plan does not have to pay for the application of multi-layer compression system coded 29851 provided on April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) provided on April 17, 2021.
You asked the Plan to pay for the extraction. You say that you opted to receive an extraction so as not to be left
with a dental bill that you could not afford. The Plan denied your request. The Plan says this service is not a
covered benefit under your dental 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
extraction (D7140) provided on April 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on April 5,
2021.
You asked the Plan to pay for the periodontal maintenance. You say that you did not understand what
periodontal maintenance (D4910) meant, nor did you know it would not be covered by your insurance. 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 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
periodontal maintenance (D4910) provided on April 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on January 18, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you called 911 because you thought you were having a stroke, but it was an anxiety attack. The Plan denied your request. The Plan says the ambulance benefit is a transport benefit and if no transport of a Medicare beneficiary occurs, then there is no Medicare covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 18, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on January 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from
April 26, 2021, to May 26, 2021.

You asked the Plan to waive the copayments for the physical therapy visits. You say that you were not
informed of the copayment and you were not asked to pay any copayments at the time of the visits.

The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 each in-network Medicare-covered therapy visit.

You have been asked to pay a $40 copayment for each of the physical therapy visits. The physical therapy
visits fall within the "Outpatient rehabilitation services" benefit category. This means that you have been asked
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive
the copayments for the physical therapy visits provided from April 26, 2021, to May 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for inpatient hospital stays provided from December 5, 2020, to December 16, 2020.
You asked the Plan to waive the copayments for inpatient hospital stays. You say that the inpatient hospital stays were related to a previous stay and you had to keep returning due to low hemoglobin and oxygen levels. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $275 copayment for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from December 5, 2020, to December 8, 2020. Therefore, you are
responsible to pay a $275 copayment for days 1-3 (December 5, 2020, to December 7, 2020). $275 (copayment) x 3 (inpatient days) = $825. You had an inpatient hospital stay from December 11, 2020, to December 16, 2020. Therefore, you are responsible to pay a $275 copayment for days 1-5 (December 11, 2020, to December 15, 2020). $275 (copayment) x 5 (inpatient days) = $1,375. The total amount you owe is: $2,200. You have been asked to pay the total copayment amount of $2,200 for inpatient hospital stays. Inpatient hospital stays fall within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for inpatient hospital stays provided from December 5, 2020, to December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the apicoectomy (D3421) and retrograde filling (D3430)
provided on April 14, 2021.
You asked the Plan to pay for the apicoectomy and retrograde filling. You say that this procedure was to
correct a failed root canal. You also say that it was the only procedure available to address a serious abscess
and should be covered. The Plan denied your request. The Plan says these services are not covered benefits
under your dental 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
apicoectomy (D3421) and retrograde filling (D3430) provided on April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on April 14, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that if your dentist did not take this x-ray you may still be in pain. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you did contact the Plan prior to this date of service to verify benefits for a cleaning and provider eligibility, but not for a problem focused limited oral evaluation and first intraoral periapical x-ray.
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 problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on April 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for hemodialysis (99512) provided form February 1, 2021, to February 12, 2021.
You asked the Plan to pay for the home health services. You say that you understand that home hemodialysis is not covered under Medicare. You say that you sought prior approval for this reason. You say that these services were approved as a covered benefit under the enrollee's plan. You also say that The Plan denied your request. The Plan says the facility in this case is not enrolled in Medicare. The Plan also says that services rendered by a provider that is not enrolled in Medicare are not eligible for payment.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the home visit for hemodialysis (99512) provided form February 1, 2021, to February 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 20, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you believe the reason for this confusion is that two offices each completed part of your comprehensive oral examination. The Plan denied your request. The Plan says this service 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 Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation (D0150) and is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on April 1, 2021 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the immune globulin injection provided from April 14, 2021, through April 16, 2021.
You asked the Plan to waive the coinsurance for the immune globulin injections. You say that the infusion place did not notify you of the cost beforehand. You say that you would have opted out of the infusions if you knew it was going to be so expensive. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered Part B drug from an in-network provider.
You have been asked to pay $848.54, which is 20% of the allowed amount for each immune globulin injection. The allowed amount is $4,242.70 (20% x $4,242.70 = $848.54). The total amount you owe is $2,545.62 ($848.54/injection x 3 injections = $2,545.62). The immune globulin injections fall within the "Medicare Part B prescription 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 the immune globulin injection provided from April 14, 2021, through April 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on January 29, 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 Medicare denies coverage for all cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease.
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 test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic testing provided on January 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the mastectomy and intraoperative identification provided on November 24, 2020.

You asked the Plan to pay for Mastectomy, simple, complete (19303) and intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (List separately in addition to code for primary procedure) (38900). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the units charged for code 19303 is wrong and code 38900 was billed with a denied primary code so code 38900 cannot be paid.

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 19303 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. The primary code is denied therefore code 38900 cannot be paid. Based on this information, we decided that Medicare rules for coverage of Mastectomy, simple, complete (19303) and intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (List separately in addition to code for primary procedure) (38900) have not been met. Therefore, we decided that the Plan does not have to pay for the mastectomy and intraoperative identification provided on November 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on April 6, 2021.

You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that this was your first visit and first time being to this provider ever. You also say that when you updated your insurance plan you were told this provider was in-network and you would have more dental coverage. The Plan denied your request. The Plan says these services exceed the maximum allowed per period.

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, comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on April 15, 2019 and your comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on April 6, 2021.