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

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 27, 2021.
You asked the Plan to pay for the limited evaluation. You say that these services were necessary, and you were referred to this provider by your in-network dentist. The Plan denied your request. The Plan says they have agreed to re-process the claim as in-network because you were referred by a contracted provider. However, the limited oral exam remains denied as this service 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 limited oral evaluation (D0140) provided on May 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a maxillary partial denture adjustment (D5421) provided on
February 2, 2021.
You asked the Plan to pay for this dental service. You say that these services should be covered by the Plan.
The Plan denied your request. The Plan says this benefit was not available at the time of service. We
overturned the Plans denial. The Plan requested a reopen and stated code D5421 (adjust Partial Denture-
Maxillary) had previously been covered. The Plan provided documentation to show that you are allowed 2
adjustments per year and the plan had already been billed and paid for two claims for this service provided on
January 12, 2021 and January 19, 2021.
The Plan is correct in this case. Medicare 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, this benefit was exhausted on January
12, 2021 and January 19, 2021 prior to the date of service in question. Therefore, we decided that the Plan does
not have to pay for a maxillary partial denture adjustment (D5421) provided on February 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Neuropathy Support Supplement from Nuturna International provided on June 12, 2021.
You asked the Plan to pay for Neuropathy Support Supplement. You say that the pain in your legs and feet have decreased by 90% and you believe this supplement should be covered just as cranberry supplements and fish oil are covered. The Plan denied your request. The Plan says under the Pick Your Perks program, Neuropathy Support Supplement is not covered. The primary ingredients, Alpha Lipoic Acid, L-Arginine HCI, as well as the proprietary blend are considered alternative medicine ingredients and not eligible under the Pick Your Perks program.
The Plan contract offers a supplemental Pick Your Perks program benefit. The benefit says over-the-counter items must be included on the Plan's allowed items list. We looked at the file and the Plan's rules. The file shows that over-the-counter items must be included on the
Plan's allowed items list. Ineligible items include but are not limited to the following: Alternative medicines such as botanicals, herbals, probiotics and nutraceuticals. The proprietary blend is considered alternative medicine ingredients and not eligible under the Pick Your Perks program. Therefore, we decided that the Plan does not have to reimburse you for Neuropathy Support Supplement provided on June 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the carotid artery stenting (37215) provided on June 15, 2021.
You asked the Plan to pay for the carotid artery stenting. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the facility is not eligible to receive payment for the service at issue.
The Plan must follow Medicare rules. Medicare rules say that Carotid Artery Stenting (CAS) with embolic protection is reasonable and necessary only if performed in facilities that have been determined to be
competent in performing the evaluation, procedure and follow-up necessary to ensure optimal patient outcomes. We looked at the file and Medicare rules. The facility that performed this stenting is not listed on the CMS list of facilities eligible to be paid for performing this service. Therefore, we decided that the Plan does not have to pay for the carotid artery stenting (37215) provided on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the reline complete maxillary denture (indirect) (D5750) and replace missing or broken teeth - complete denture (each tooth) (D5520) provided by an out-of-network (OON) dentist on May 19, 2021.
You asked the Plan to pay for the upper denture reline and replacement of missing or broken teeth on denture. You say that you were dissatisfied with the Plan's network dentists and feel the service should be covered OON because you received good care. The Plan denied your request. The Plan says OON 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. The Plan covers the upper denture reline and replacement of missing or broken teeth on denture when the services are medically necessary and reasonable.
We looked at the file and Medicare rules. 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 items/services. Based on this information, we decided that the Plan's rules for coverage of the upper denture reline and replacement of missing or broken teeth on denture have not been met. Therefore, we decided that the Plan does not have to pay for the reline complete maxillary denture (indirect) (D5750) and replace missing or broken teeth - complete denture (each tooth) (D5520) provided by an out-of-network (OON) dentist on May 19, 2021.
Your complaint about the Plan's dental network 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasonic guidance for needle placement (76942-26) provided on July 9, 2021.
You asked the Plan to pay for code 76942. 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. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76942
is a column II code to column I code 76937. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasonic guidance for needle placement (76942-26) provided on July 9, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant
(D6010) for tooth #5.
You asked the Plan to pre-approve a dental implant. You say that this implant should be covered. The Plan
denied your request. The Plan says coverage requirements for this dental service are not met. We
overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says
that code D6010 described as surgical placement of implant body: endosteal implant for tooth #5 was originally
denied. The Plan states implants are covered to replace only one tooth in the same part of your mouth.
The Plan states the dental records show the dentist has asked to replace more than one tooth in this part of your
mouth with an implant. This Plan states the dentist submitted two separate authorization requests for implants
for you. The Plan states on May 10, 2021 the dentist requested code D6010 for surgical placement of implant
body: endosteal implants for teeth #6, #14, #15, #19, and #20. On May 13, 2021 the dentist requested code
D6010 for tooth #5 under a different authorization. It is clear the dentist requested to replace more than one
tooth in this area of the mouth and multiple implants were planned, which is not covered under the dental
benefit.
The Plan is correct in this case. 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 implants are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a surgical
placement of implant body: endosteal implant (D6010) for tooth #5.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient services provided from November 9, 2020, through December 16, 2020.  You asked the Plan to pay for inpatient services. The Plan denied your request. The Plan says if the enrollee needs medical care that Medicare requires our Plan to cover, and the providers in our network cannot provide this care, the enrollee can get this care from an out-of-network provider. The medical care will be coordinated with an out-of-network provider. Prior authorization from our Plan must be obtained prior to obtaining services.   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 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 inpatient services provided from November 9, 2020, through December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseous surgery (D4261) and bone replacement grafts (D4263).
You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by the Plan's dental 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 pre-approve osseous surgery (D4261) and bone replacement grafts (D4263).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, non-emergency transport (A0428) provided July 2, 2021.
You asked the Plan to waive the copayment for the non-emergency ambulance transport. You say that the enrollee needed to go to a different hospital for the necessary services. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $275 copayment for each one-way Medicare-covered ambulance transport. The enrollee has been asked to pay a $275 copayment for the non-emergency ambulance transport. The non-emergency ambulance transport falls within the Ambulance services 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 the ambulance service, basic life support, non-emergency transport (A0428) provided July 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services (71045) provided on April 13, 2021.
You asked the Plan to pay for code 71045. 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. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045 is a column II code to column I code 36584. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services (71045) provided on April 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the LifeVest provided on May 2, 2021.
You asked the Plan to waive the coinsurance for the LifeVest. You say that you did not agree to take the item and that you had already sent back the machine. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare-covered durable medical equipment (DME) items and certain drugs that are used with nebulizers, insulin pumps, and intravenous infusion pumps. You have been asked to pay $586.29 which is 20% of the allowed amount for the LifeVest. The allowed amount is $2,931.45. ($2,931.45 x 20% = $586.29). The LifeVest falls within the "Durable Medical Equipment (DME) and Related Supplies: 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 LifeVest provided on May 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided on January 13, 2021.  You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged. 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 laboratory services provided on January 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for laboratory services provided on July 15,
2021.
You asked the Plan to waive the coinsurance for laboratory services. You say that you should not be charged
for laboratory services. 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 $0
copayment for lab services provided at a primary care providers office, specialists office, or a freestanding
facility, a $15 copayment when provided at an urgent care facility and 20% coinsurance when provided at an
outpatient hospital facility.
You received laboratory services at an outpatient hospital facility on July 15, 2021. Therefore, you are
responsible to pay your share of the cost-sharing charges. The total allowed amount is $118.83 and 20% of that
is $23.77.
You have been asked to pay $23.77 for laboratory services. Laboratory services fall within the outpatient
diagnostic tests and therapeutic services and supplies 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 laboratory services provided on July 15, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80307, 83789, G0480) rendered by the out-of-network (OON) provider on June 17, 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 laboratory services (80307, 83789, G0480) rendered by the out-of-network (OON) provider on June 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for Abatacept injections provided on February 12, 2021, and April 19, 2021.  You asked the Plan to waive the coinsurance for the injections. You say that you are disputing the charges. The Plan denied your request. The Plan says the correct coinsurance was 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 20% coinsurance for chemotherapy drugs.      Date of Service Service Provided Allowed Amount 20% Coinsurance February 12, 2021 Drug Administration $288.64 $57.73  Abatacept Drug $3118.28 $623.66 April 19, 2021 Drug Administration $288.64 $57.73  Abatacept Drug $3171.15 $634.23 Total   $1373.35   You have been asked to pay $1373.35 for the injections received on February 12, 2021, and April 19, 2021. Chemotherapy injections fall within the Medicare Part B Prescription Drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Abatacept injections provided on February 12, 2021, and April 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on March 30, 2021.
You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says that the Plan does not offer reimbursements for hearing aids or services purchased out-of-network.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the Plan's hearing aid provider. We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on March 30, 2021.