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

We decided that the Plan does not have to pay for the dental services provided from July 23, 2020, through April 12, 2021.
You asked the Plan to pay for the dental services. You say that you'd like to know why they are not covering any routine exam or x-rays. The Plan denied your request. The Plan says out-of-network dental services are 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided from July 23, 2020, through April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2391) provided on April 28, 2021.
You asked the Plan to pay for the resin-based composite. You say that your dentist does not provide amalgam fillings, and composite fillings are the only type of filling available and your dentist's office. You also say that you prefer not getting mercury fillings due to health concerns. 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 resin-based composite (D2391) provided on April 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a transtelephonic evaluation of a pacemaker system (93293) provided on April 20, 2021, by an out-of-network provider.
You asked the Plan to pay for a transtelephonic evaluation of a pacemaker system. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. 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 a transtelephonic evaluation of a pacemaker system (93293) provided on April 20, 2021, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology testing provided on April 19, 2021 by an
out-of-network (OON) provider.

You asked the Plan to pay for the cytopathology testing. You say that the service was medically necessary. The
Plan denied your request. The Plan says no prior authorization was obtained.

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. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the cytopathology testing provided on April 19, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance provided on June 1, 2021.
You asked the Plan to pay for periodontal maintenance. You say that you were told the services are covered then were told the periodontal maintenance was not covered. The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for periodontal maintenance provided on June 1, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on June 2, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you refuse to pay this copayment because you did not receive any services. You said that the nurse came in and took your blood pressure. You said that the doctor came in and evaluated you with a stethoscope and advised you to go home and rest. The Plan denied your request. The Plan says you were charged this copayment 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 $120 copayment for emergency room services. You have been asked to pay a $120 copayment for the ER visit. According to the case file information, you were triaged in the emergency room by a nurse and seen by a doctor.
The ER copayment applies regardless of the extent of services you receive. 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 the emergency room (ER) visit you had on June 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.

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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis.
The requested Superion spacer is considered experimental in nature, as more research is needed to show safety
and efficacy. The services are therefore not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for dental pathology services (88305) provided on April 14, 2021.
You asked the Plan to pay for dental pathology services. You say that this was covered in the past. The Plan denied your request. The Plan says this is not a covered service.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for dental pathology services (88305) provided on April 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skin lesion destruction procedure you
had at an outpatient hospital facility on April 6, 2021.
You asked the Plan to waive the copayment for the skin lesion destruction procedure. You say that this
procedure should not be considered surgery as it only took 10-15 minutes. The Plan denied your request. The
Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this
procedure ($196.49) is less than your copayment obligation, you are responsible for the full allowed 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 $350
copayment for surgery or other services at an outpatient hospital facility. You have been asked to pay a $350 copayment for the skin lesion destruction procedure. Medicare considers
skin lesion destruction procedures to be surgical procedures. In addition, the facility that billed for this service
is considered an outpatient hospital facility. That is why the skin lesion destruction procedure falls within the
surgery or other services at an outpatient hospital facility 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 the skin lesion destruction procedure you had at an outpatient hospital facility on
April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the optometry services provided on March 16, 2021, by an
OON provider.
You asked the Plan to pay for optometry services. You say that the enrollee could not choose an-in-network
provider during the coronavirus pandemic. The Plan denied your request. The Plan says no prior authorization
was obtained.
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 optometry services provided on March 16,
2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (88165 and 86334) provided August 20, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says it is the provider's responsibility to bill the Primary Group Health Plan or any liability insurance before submitting the claim to the member's Plan.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the laboratory services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (88165 and 86334) provided August 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on May 6, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the Guardant360 panel rendered on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the complete upper and lower denture provided on February 23, 2021.
You asked the Plan to pay more for the complete upper and lower denture. You say that you already paid the dentist and you should be sent reimbursement. The Plan denied your request. The Plan says you have received the maximum reimbursement.
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, you also have an annual maximum of $1,000. The Plan paid $1,000 toward the dentures provided on February 23, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay more for the complete upper and lower denture provided on February 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve the additional routine transportation trips. You say that additional trips are needed to get to medical appointments. The Plan denied your request. The Plan says the enrollee has exceeded the benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 52 one-way routine transportation trips per year. We looked at your request, the records in the case file, and the rules. The records show that you received coverage for 52 one-way routine transportation trips in the 2021 calendar year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided from February 1, 2021, to March 23, 2021.
You asked the Plan to pay for psychotherapy services (90792, 99213,90836) from an ineligible provider. You say that in-network providers were not able to get you well. The Plan denied your request. The Plan says this provider is not a Medicare-certified provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from February 1, 2021, to March 23, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99283) provided on February 18, 2021.

You asked the Plan to pay for an emergency room visit. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with an appropriate diagnosis.

The Plan follows Medicare rules. The rules say that screening is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease. The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test. 

We looked at the file and Medicare rules. The service at issue was billed with diagnosis Z13.9, encounter for screening, unspecified, but the record shows that this was not a screening service. This service was provided in relation to signs or symptoms. Therefore, we decided that the Plan does not have to pay for an emergency room visit (99283) provided on February 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost sharing for the echocardiography and the contrast
material supplies you received on March 29, 2021.

You asked the Plan to reduce the cost sharing for the echocardiography and contrast material. You say that
your doctor ordered this test to see if you had any heart issues. You said that Medicare covers this procedure,
and you should have only paid a $40 copayment. The Plan denied your request. The Plan says you were
charged this cost sharing 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 $160
copayment for diagnostic radiological services in a doctor's office or freestanding facility and 20% coinsurance
for medical supplies (including chemical agents used in certain diagnostic procedures.)

You have been asked to pay a $160 copayment for the echocardiography and 20% coinsurance for the contrast
material. The echocardiography falls within the diagnostic radiological services in a doctor's office or
freestanding facility benefit category. In addition, the contrast material is a chemical agent used during a
diagnostic procedure, so it is considered a medical supply. 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 cost sharing
for the echocardiography and the contrast material supplies you received on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you received from March 1, 2021, to March 17, 2021.
You asked the Plan to waive the copayment for the SNF services. You say that you do not agree with this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $184 copayment per day for days 21-100 for skilled nursing facility services. Records show that you were in the SNF from February 24, 2021 until March 17, 2021, a total of 22 days, minus the day of discharge, for a total of 21 billed days. You were charged $0 per day for days 1-20. For day 21, you were charged a copayment of $184. 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 skilled nursing facility (SNF) services you received from March 1, 2021, to March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services.

You asked the Plan to pre-approve the requested services. You say that you would like to finish chiropractic treatment to avoid back surgery. The Plan denied your request. The Plan says maintenance treatment is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 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 requested services. Our physician reviewer found that in this case, the record indicates you experienced an injury in December 2020 and received chiropractic services. The documentation indicates your clinical improvement has plateaued. The record does not indicate that you are reasonably expected to continue to improve. Therefore, the requested services are not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 3, 2021.
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on January 3, 2021.