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

We decided that the Plan does not have to pay for the laboratory services provided on April 5, 2021 by a non-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The referring provider is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 5, 2021 by a non-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88112) provided on May 3, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for laboratory services. You say that this should not be considered out-of-network because the enrollee did not come to the laboratory. The Plan denied your request. The Plan says this was not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services (88112) provided on May 3, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81185, 81401, 81403, 81404, 81405, 81406, & 81479) provided November 27, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed 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. The rules also state that Medicare denies coverage for all cardiovascular risk assessment panels.

We find that CPT codes 81185, 81401, 81403, 81404, 81405, 81406, & 81479 are not supported in the medical record. Specifically, the place of service on the claim form (81, lab) does not match the place of service detailed in the records (11, office setting). Furthermore, the tests at issue are non-covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81185, 81401, 81403, 81404, 81405, 81406, & 81479) provided November 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more toward the extractions, panoramic radiographic image,
drugs or medicaments, biologic materials to aid in soft and osseous tissue regeneration, guided tissue
regeneration and bone replacement graft provided on May 13, 2021.
You asked the Plan to pay more toward the extractions, panoramic radiographic image, drugs or medicaments,
biologic materials to aid in soft and osseous tissue regeneration, guided tissue regeneration and bone
replacement graft. You say that you needed this done and this was incorrectly filed. You say that you paid
$9,800 and more than $112 should be paid. 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 Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is only obligated to pay 45%
of the allowed amount for the extractions. The remaining services are not covered benefits. Therefore, we
decided that the Plan does not have to pay more toward the extractions, panoramic radiographic image, drugs
or medicaments, biologic materials to aid in soft and osseous tissue regeneration, guided tissue regeneration
and bone replacement graft provided on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the gym membership.

You asked the Plan to pay more for the gym membership. You say that you were charged double fees and were told you would receive a monthly credit. You say that the total reimbursement should be $203.98. The Plan denied your request. The Plan says $134.98 will be reimbursed and the remaining $69 will be denied.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $300 each calendar year toward gym benefits.

The Plan's rules for additional coverage of gym benefits have not been met because Specifically, the records show the Plan reimbursed the proper amount toward the cost of your gym membership. Therefore, we decided that the Plan does not have to pay more for the gym membership.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) provided on April 22, 2021.
You asked the Plan to pay for the adjunctive pre-diagnostic test. You say that you were told this was an in-network provider and they accepted your insurance. The Plan denied your request. The Plan says they have agreed to make an exception in this case and process the claims from April 22, 2021, and May 10, 2021, as in-network due to a misunderstanding. The extractions, oral exam and x-rays are now covered, but the adjunctive pre-diagnostic test is not covered by your dental benefit regardless of the network status of the provider.
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 pre-diagnostic test (D0431) provided on April 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing provided on February 3, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the coverage criteria are not met.
The Plan follows Medicare rules. Medicare rules say that ConfirmMDx testing is covered when the criteria in the applicable LCD 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 pay for the testing. Our reviewer says that the requested ConfirmMDx testing was not medically reasonable and necessary. Our physician reviewer found that per the pathology report, one out of 12 cores was positive for cellular atypia. Per provider documentation on February 17, 2021, prostate core is positive for atypical proliferation and the enrollee is interested in TURP. There is no documentation showing that the enrollee is being considered for repeat biopsy. The requested test is not indicated if previous histology included cellular atypia suspicious for cancer. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing provided on February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on June 18, 2021, to June 25, 2021.

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 are not covered.

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. The file shows that the
provider billed procedure code 99212 (office visit). Therefore, we decided that the Plan does not have to pay
for the office visit rendered on June 18, 2021, to June 25, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on November 24, 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 procedure code 99285 is not supported.
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, the CPT Code Manual definition of code 99285 is Level 5 emergency department visit for evaluation and management of patient with problem immediately threatening life, including comprehensive history and physical examination, and medical decision-making of high complexity. We find that CPT code 99285 is not supported in the medical record. Specifically, the records do not support
the Level 5 complexity of services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services rendered on November 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for surgical removal of a venous access device provided on June 7, 2021.
You asked the Plan to waive the copayment for specialist service. You say that you do not know this doctor and do not know why you have a copayment for a procedure like this. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $40 copayment for in-network specialist visit for surgical service.
You have been asked to pay $40 copayment for specialist service. Specialist service falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 surgical removal of a venous access device provided on June 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or at the home with home health care services.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 8, 2021 to April 1, 2021 by an non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The 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 office visit provided on March 8, 2021 to April 1, 2021 by an non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay and additional amount for the cone beam computed tomography (CT) (D0364) and comprehensive oral evaluation provided on May 10, 2021, by an out of network provider.
You asked the Plan to pay and additional amount for the dental services. You say that you were not aware that the provider was out of network. You say that you cannot afford to pay the out of pocket cost. You also say that you are on disability and did not understand. The Plan denied your request. The Plan says cone beam CT is not
listed as a covered service. The Plan also says that nonparticipating providers may bill you for any amount greater than the what the plan pays.
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 cone beam CT is not among those covered under this benefit. Additionally, nonparticipating providers may bill you for any amount greater than the what the plan pays. 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 cone beam computed tomography (CT) (D0364) and comprehensive oral evaluation provided on May 10, 2021, by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lower denture reline (D5731) provided on May 18, 2021.
You asked the Plan to pay for the dental service. You say that you did not realize that the denture adjustment would not be covered for both the top and bottom denture. You say that your dentist was not able to do the top and bottom at the same time. You also say that you do not have $240 to pay this bill. The Plan denied your request. The Plan says 1 upper denture reline or 1 lower denture reline is covered per calendar year. The Plan also says that the frequency limit has 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 and denture reline is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for an upper denture reline that you received on April 28, 2021. Therefore, we decided that the Plan does not have to pay for the lower denture reline (D5731) provided on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the complete upper denture (D5110) and the complete lower denture (D5120) provided on May 10, 2021.
You asked the Plan to pay the full amount for the dental item. You say that you were not told you did not qualify for denture until after you received the denture. You say that if you had known, you would not have gotten the dentures. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says there is a $1,500 allowance every year for dental services. The Plan also says that the annual allowance has been exhausted.
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 dentures are covered services, the annual allowance has been exhausted. The record shows that the Plan paid $259.50 for dental services you received on February 1, 2021, and $1,240.50 towards dental services received on May 10, 2021. $259.50+$1,240.50=$1,500. You are responsible for any amount over the annual allowance. Therefore, we decided that the Plan does not have to pay the full amount for the complete upper denture (D5110) and the complete lower denture (D5120) provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 21, 2021.
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on May 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 9, 2020.
You asked the Plan to pay for the laboratory 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services and vitamin injections provided on
September 9, 2020.

You asked the Plan to pay for the therapy services and vitamin injections. You say that these procedures codes
are valid and properly coded based on the type of treatment performed. You say that the medical records
demonstrate the medical necessity of the service proving they are not experimental or investigational. The Plan
denied your request. The Plan says this does not meet guidance for coverage.

The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical
therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private
practice. Medicare rules say that that beginning in July 2015, claims for compounded drugs shall be submitted
using a compounded drug, not otherwise classified (NOC) code.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the therapy services and vitamin injections have not been met. Review of the file and publicly
available records, we find that the therapy services at issue in this case were rendered by an NP who is not
licensed to provide physical therapy in the State of Virginia.

The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The
rules require that any compounded drug be billed using the not otherwise classified code J7999. As this
compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed,
the drug administration code, 96372, also cannot be paid. Therefore, we decided that the Plan does not have to
pay for the therapy services and vitamin injections provided on September 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultralightweight wheelchair (K0005) with accessories
provided on March 12, 2021.
You asked the Plan to pay for an ultralightweight wheelchair with accessories. You say that the requested items
are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have
not been met due to unsolicited phone contact by the supplier.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone
regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the
enrollee's treating physician. The record does not show that written permission was obtained to make contact
by telephone regarding the furnishing of this item. The record does not show that contact was initiated
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the
past 15 months. Based on this information, we decided that Medicare rules for coverage of an ultralightweight
wheelchair with accessories have not been met. Therefore, we decided that the Plan does not have to pay for an
ultralightweight wheelchair (K0005) with accessories provided on March 12, 2021.