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

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first
intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), two anterior resin-based
composites of three surfaces (D2332), anterior resin-based composite of four surfaces (D2335), posterior resin-
based composite of three surfaces (D2393), and posterior resin-based composite of four or more surfaces
(D2394) provided from May 20, 2021, to June 11, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation, intraoral periapical x-rays, and
resin-based composites. You say that the Plan did not send a Notice of Denial of Payment to you or your
dentist prior to you receiving these services. You also say that you have incurred expenses that you are not able
to pay at this time. The Plan denied your request. The Plan says the problem focused limited oral evaluation is
not a covered service. The Plan also says that your benefits for the intraoral x-rays and resin-based composite
have been satisfied and the frequency limitations have been exceeded.
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, problem focused limited oral
evaluation (D0140) is not among those covered under this benefit. The Plan contract says that intraoral x-rays
are limited to one procedure code per calendar year. The record shows that you received a first intraoral
periapical x-ray (D0220) on May 3, 2021 and your intraoral x-rays benefit has been exhausted. The contract
also says that restorations (fillings) are limited to two procedure codes per calendar year. The record shows that
you received two resin-based composites on April 29, 2021 and your restorations benefit has been exhausted.
The Plan also says that they did receive a predetermination request for the restorations, but you went ahead and
received the services prior to completion of the predetermination request. Therefore, we decided that the Plan
does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray
(D0220), each additional intraoral periapical x-ray (D0230), two anterior resin-based composites of three
surfaces (D2332), anterior resin-based composite of four surfaces (D2335), posterior resin-based composite of
three surfaces (D2393), and posterior resin-based composite of four or more surfaces (D2394) provided from
May 20, 2021, to June 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services rendered from January 11, 2021, to March 9, 2021.
You asked the Plan to waive the copayment for inpatient hospital services. You say that you were transferred for special care since you had low oxygen levels due to the coronavirus (Covid-19). You also say you were told by the Plan that you would only have to pay for your first four days at the Hospital and now you received another bill for the first four days. The Plan denied your request. The Plan says you were charged 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 $465 copayment per each Medicare-covered day for days 1-4 for in-network, inpatient hospital care.
The Plan contract also says that the cost sharing described in the previous sentence applies each time you are admitted to a hospital. It is considered a new admission if you are transferred from a hospital to a separate type of facility (such as an acute inpatient rehabilitation hospital or a long-term care hospital). You have been asked to pay a $465 copayment for each Medicare-covered day for days 1-4 for inpatient hospital services, for a total of $1,860 ($465 x 4 = $1,860). The record shows that you were transferred from one type of inpatient hospital to another type of inpatient hospital, which is considered a new admission. 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 inpatient hospital services rendered from January 11, 2021, to March 9, 2021.
Your complaint about potentially being given incorrect information by the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an office visits with an out of network (OON) provider.
You asked the Plan to pre-approve the OON office visits. You say that you have a condition called Hypoparathyroidism and need to be seen by the requested OON specialist, as they are the only ones who treat your condition. You say that you would like this covered at the in-network rate due to medical necessity. You say that you have been seen by multiple doctors in the network and none know how to treat you. The Plan denied your request. The Plan says that there are several participating specialists that are able to treat the enrollee's condition.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.
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 OON office visits. Our reviewer says that the criteria for coverage of OON care have been met. Our physician reviewer found the enrollee had thyroid surgery and has developed post-operative hypoparathyroidism. The records show that the enrollee has seen other endocrinologists for this condition and has had poor control with kidney stones and urine infections. The enrollee's treating physician at the clinic has recommended that the enrollee see the requested OON provider who has expertise in this area. The documentation does not demonstrate that the Plan is offering adequate care to meet the enrollee's needs through referral to their network of providers. The enrollee's condition and situation is unique and it is medically necessary to see the requested OON provider. 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 OON office visits have been met. Therefore, we decided that the Plan has to pre-approve an office visits with an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IORT with electronic brachytherapy (CPT code 0395T).
You asked the Plan to pre-approve the service. You say that IORT with electronic brachytherapy is medically
necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of IORT with
electronic brachytherapy in the setting of left breast cancer has not been demonstrated in the peer-reviewed
literature.
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 service. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found they do not believe that IORT with electronic brachytherapy is within accepted standards 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 the service have not been met. Therefore, we decided that the Plan does not
have to pre-approve IORT with electronic brachytherapy (CPT code 0395T).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation (CPT code 99203) to be provided by
out-of-network providers.
You asked the Plan to pre-approve the consultation. You say that you are requesting review of denial of
services. The Plan denied your request. The Plan says the service requested can be safely rendered in-network.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the consultation (CPT code 99203) to be provided by out-of-network providers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140)
provided July 23, 2021.
You asked the Plan to pay for the limited, problem focused oral exam. You say that this service was medically
necessary for follow-up care for an extraction. The Plan denied your request. The Plan says you have exceeded
the frequency limit for this 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. The Plan covers the limited,
problem focused oral exam once every 12 months.
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited, problem
focused exam was previously covered on April 30, 2021. Based on this information, we decided that the Plan's
frequency limit for coverage of the limited, problem focused oral exam has been exceeded. Therefore, we
decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided
July 23, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen services provided on January 1, 2020 by an out of network provider.
You asked the Plan to pay for the oxygen concentrator. You say that you want the provider to be in-network. The Plan denied your request. The Plan says you did not request 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 has network providers available who can provide 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 oxygen services provided on January 1, 2020 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compressor (E0651) and segmental
pneumatic appliances (E0667 x 2) to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says there are in-network providers available to render the
requested items.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items at issue in this appeal.
We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the
Plan does not have to pre-approve a pneumatic compressor (E0651) and segmental pneumatic appliances
(E0667 x 2) to be rendered by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for periodontal scaling and root planing
(D4341) provided by a participating provider on May 10, 2021.
You asked the Plan to waive the copayment for periodontal scaling and root planing. You say that the Plan is
supposed to pay 100% for cleanings. The Plan denied your request. The Plan says the correct coinsurance has
been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 70%
coinsurance for scaling and root planing/in-network.
You have been asked to pay a 70% coinsurance of the allowed amount for periodontal scaling and root planing.
The total allowed amount is $700. The total amount you are being asked to pay is $490 ($700 x 70% = $490).
Periodontal scaling and root planing falls within the scaling and root planing/in-network 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 periodontal scaling and root planing (D4341) provided by a
participating provider on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on June 15, 2021.
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says hearing aids are
not covered under any condition.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related
services.
Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these
types of items and services. Therefore, we decided that the Plan does not have to pay for the hearing aids
provided on June 15, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (CPT code G0483) provided to the enrollee on
April 1, 2021.
You asked the Plan to pay for the drug test. You say that the claim should be paid. The Plan denied your
request. The Plan says the service is not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the drug test have not been met. CPT code G0483-90 remains not
supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when
the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a
laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the
specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the
specimen was collected on April 1, 2021, and received by the lab on April 5, 2021; therefore, the billed code
cannot be verified. Therefore, we decided that the Plan does not have to pay for the drug test (CPT code
G0483) provided to the enrollee on April 1, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee requires continued acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility.   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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services provided on January 31, 2021.  You asked the Plan to pay for the anesthesia services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that Medicare coverage criteria had been met for the claim in dispute. The appeal is for one CRNA; however, the medical records provided show a different CRNA provided the services at issue. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on January 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye exam (92012) with refraction (92015) and eyeglasses (V2020, V2103) provided on July 22, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the vision services. You say that the enrollee's nursing facility coordinates their care, and the provider relies on the nursing facility to obtain authorization. These services were rendered in good faith. The Plan denied your request. The Plan says they do not cover out of network services except in certain limited circumstances. The rendering provider is not part of the Plan's network, and the services were not referred by a network provider. There is no evidence that the services provided were urgent or emergent. Therefore, payment is denied.  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 eye exam (92012) with refraction (92015) and eyeglasses (V2020, V2103) provided on July 22, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing provided on May 4, 2021.  You asked the Plan to pay for lab tests. 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 the documentation submitted does not support the Place of Service (POS) code billed on this claim.    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 documentation submitted shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve medial branch blocks (MBB)/facet joint blocks.  You asked the Plan to pre-approve medial branch blocks/facet joint blocks. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  The Plan follows Medicare rules. Medicare rules say that medial branch blocks/facet joint blocks are only covered for certain indications.  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 medial branch blocks/facet joint blocks. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic neck pain and is status post C4-C7 fusion. The enrollee has had physical therapy and is status post radiofrequency ablation (RFA) of the cervical spine in August 2020, which gave effective relief. In this case, the enrollee has had a successful RFA in 2020. Per the LCD criteria, diagnostic injections or MBB at the same level as the previously successful RFA procedure are not medically necessary or reasonable. Therefore, the enrollee does not meet criteria for the requested services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of medial branch blocks/facet joint blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve medial branch blocks (MBB)/facet joint blocks.