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

 We decided that the Plan does not have to pay for the extraction (D7140), retainer crown (D6740), and pontic (D6245), provided on March 3, 2021.  You asked the Plan to pay for the extraction, retainer crown, and pontic. You say that the services should be covered. The Plan denied your request. The Plan says these are not covered services.  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), retainer crown (D6740), and pontic (D6245), provided on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the IV tubing extension set (S1015) and infection control supplies (S8301) provided on May 12, 2021.  You asked the Plan to pay for the medical equipment. You say that you would like these claims reprocessed based on the medical documentation. The Plan denied your request. The Plan says these codes as billed are not valid for Medicare purposes.  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 S1015 is IV tubing extension set and S8301 is infection control supplies, not otherwise specified.  We find that CPT codes S1015 and S8301 are not eligible for payment. Specifically, these codes have a status code of "I" under the Physician Fee Schedule. This indication means that the codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the medical equipment have not been met. Therefore, we decided that the Plan does not have to pay for the IV tubing extension set (S1015) and infection control supplies (S8301) provided on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the Prolia injection you received on August 12, 2021.  You asked the Plan to waive the coinsurance for the Prolia injection. You say that when you called, you were told your cost sharing would only be $4.19. The Plan denied your request. The Plan says you were charged this coinsurance 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 Medicare Part B drugs.   You have been asked to pay 20% coinsurance for the Prolia injection. The Prolia injection falls within the Medicare Part B 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 Prolia injection you received on August 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient services provided from November
2, 2020, to November 11, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you believe the
insurance coverage covers his stay. The Plan denied your request. The Plan says the enrollee has been 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). The enrollee's contract with the Plan clearly says that enrollees
must pay $200 per day for days 1-5 and $0 per day after day 5 for inpatient care.
The record shows the enrollee was in the hospital from November 2, 2020, to November 11, 2020. The enrollee
has been asked to pay $200 per day for the first five days of the inpatient hospital services. The total for the
stay is $1000 ($200 copayment x 5 days = $1000). Inpatient hospital services fall within the Inpatient Hospital Care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient services provided from November 2, 2020, to November 11, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the IV tubing extension set (S1015) and infection control supplies (S8301) provided on May 28, 2021.
You asked the Plan to pay for the IV tubing extension set and infection control supplies. You say that you would like these claims reprocessed based on the medical records submitted. The Plan denied your request. The Plan says these codes are not eligible for payment under Medicare rules.
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 S1015 is IV tubing extension set and code S8310 is
infection control supplies, not otherwise specified. We find that CPT codes S1015 and S8301 are not eligible for payment. Specifically, these services both have a status indicator of "I" under the Physician Fee Schedule which means these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the IV tubing extension set and infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for the IV tubing extension set (S1015) and infection control supplies (S8301) provided on May 28, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic (D6240), and retainer crown (D6750), provided on July 8, 2021.
You asked the Plan to pay for the pontic and retainer crown. You say that the services should be covered. The Plan denied your request. The Plan says your liability amounts were applied correctly
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 pontic (D6240), and retainer crown (D6750), provided on July 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing (CPT code G0483) provided to the enrollee on December 16, 2020, by out-of-network providers.  You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.  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 drug testing (CPT code G0483) provided to the enrollee on December 16, 2020, by out-of-network providers.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-emergent ambulance transport (A0428) and mileage (A0425), provided on June 4, 2021.  You asked the Plan to pay for the non-emergent ambulance transport and mileage. You say that the service was medically necessary. The Plan denied your request. The Plan says there was no emergent or urgent condition that required an ambulance transport.  The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination.   The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transport (A0428) and mileage (A0425), provided on June 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87496, 87498,
87502, 87532, 87541, 87581, 87634, 87640, and 87798) provided to the enrollee on August 21, 2020.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied
your request. The Plan says the services are not covered as billed.
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 laboratory services have not been met. CPT code(s): 87486,
87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798, remain 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 a Nursing and Rehabilitation POS 31. Also, the laboratory results submitted indicate the specimen
was collected on August 21, 2020, and received by the lab on August 25, 2020. Of note, the enrollee resides in
Maryland (MD) and the billing laboratory is located in Arizona (AZ); therefore, the billed code cannot be
verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore,
we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87496, 87498,
87502, 87532, 87541, 87581, 87634, 87640, and 87798) provided to the enrollee on August 21, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis panel (CPT code 81455) provided to the enrollee on May 11, 2021.
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied your request. The Plan says this service is not covered as billed. 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 laboratory service have not been met. Genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis panel (CPT code 81455) provided to the enrollee on May 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric services.  You asked the Plan to pre-approve inpatient psychiatric services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 inpatient psychiatric services. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, you do not meet the criteria for continued acute inpatient mental health treatment for the dates in question of November 15, 2021 forward as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. You were not showing any aggressive behaviors, or any treatment required for acute threats of safety.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a second x-ray (71045) provided on June 6, 2021.  You asked the Plan to pay for a second x-ray. You say that this is supported in the records. The Plan denied your request. The Plan says only one unit of this code is supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.  We find that a second unit of CPT code 71045 is not supported in the medical record. The medical record only supports 1 unit of CPT code 71045, which was previous billed and paid. Based on this information, we decided that Medicare rules for coverage of a second x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a second x-ray (71045) provided on June 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning (D1110), and oral exam (D0150), provided on August 12, 2021.
You asked the Plan to pay for the oral exam and dental cleaning. You say that the services should be covered. The Plan denied your request. The Plan says you received the services out-of-network.
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 dental cleaning (D1110), and oral exam (D0150), provided on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 9, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you were told that copayments were waived for the remainder of the year. 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 $45 copayment for specialist services. You had a specialist visit on December 9, 2020. Specialist visits are not included in the coronavirus waiver. Therefore, you are responsible to pay the $45 copayment.
You have been asked to pay a $45 copayment for a specialist visit. A specialist visit 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 a specialist visit provided on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99203) and mechanical traction (97012) provided September 14, 2020 to September 30, 2020.  You asked the Plan to pay for the chiropractic services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor.  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. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99203) and mechanical traction (97012) provided September 14, 2020 to September 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81328, 81335, 81355, 81373, 81401) provided on April 24, 2021.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that 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 testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81328, 81335, 81355, 81373, 81401) provided on April 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prophylaxis (D1110), and periodic oral evaluation (D0120), provided on August 4, 2021.  You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that the services should be covered. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation 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, 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 prophylaxis (D1110), and periodic oral evaluation (D0120), provided on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chronic care management services (99490) rendered by
the out-of-network (OON) provider on March 2, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
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 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 services 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 the chronic care management services (99490) rendered by the out-of-network
(OON) provider on March 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the coronavirus testing (U0003, U0005) provided on March 23, 2021.  You asked the Plan to pay for the laboratory testing. You say that the referring provider ordered specialized testing for the enrollee. You say that the tests were forwarded directly to this facility. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the coronavirus testing (U0003, U0005) provided on March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant maintenance procedure (D6080) provided on August 9, 2021.
You asked the Plan to pay for the implant maintenance procedure (D6080). You say that the implant bar has three implants holding it in your jaw and the implants need to be cleaned. You say that you do not understand why a routine cleaning would not be 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 the implant maintenance procedure (D6080) provided on August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation provided on August 13, 2021.
You asked the Plan to pay for the limited oral evaluation. You say that the visit was for a broken tooth that will
need a crown. You say that this was not a situation you could wait, and payment should be reconsidered. The
Plan denied your request. The Plan says the service exceeds the frequency limitation in the 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, you also have a maximum benefit of
one limited oral evaluation per plan year. The Plan paid for the limited oral evaluation provided on January 26,
2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited
oral evaluation provided on August 13, 2021.