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

We decided that the Plan does not have to pre-approve a complete denture - mandibular (D5120).

You asked the Plan to pre-approve a complete lower denture. You say that you were in an accident and need coverage for this service. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a complete lower denture once every five years. 

We looked at the file and Medicare rules. The Plan provided documentation showing that a complete lower denture was previously covered December 13, 2017. Based on this information, we decided that the Plan's frequency limit for coverage of a complete lower denture would be exceeded with the requested service. Therefore, we decided that the Plan does not have to pre-approve a complete denture - mandibular (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction provided on October 16, 2020.
You asked the Plan to pay for the refraction. You say that you cannot pay due to your financial situation. The
Plan denied your request. The Plan says you have reached the maximum benefit for this service.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. Medicare and the Plan do not cover refractions.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the
refraction provided on October 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Radiofrequency Ablations (64635, 64636).
You asked the Plan to pre-approve the Radiofrequency Ablations. You say that the service is medically necessary. The Plan denied your request. The Plan says the enrollee has exhausted the allowed frequency for this service.
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Radiofrequency Ablations have not been met. Specifically, the member has already received this service twice in the past twelve rolling months. Therefore, we decided that the Plan does not have to pre-approve the Radiofrequency Ablations (64635, 64636).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an outpatient clinic visit (G0463) and an
incision and drainage of abscess (10060) provided on April 26, 2021.

You asked the Plan to waive the copayments for an outpatient clinic visit and an incision and drainage of
abscess. You say that you are appealing the charge as it is excessive. The Plan denied your request. The Plan
says the correct copayments were 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 $275
copayment for Medicare-covered surgery or other services provided at an outpatient hospital and a $30
copayment for each visit in a contracted Urgent Care Center or walk-in clinic.

You have been asked to pay a $169.64 copayment for an incision and drainage of abscess. An incision and
drainage of abscess falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital
Outpatient Facilities and Ambulatory Surgical Centers" benefit category. You have also been asked to pay a
$30 copayment for an outpatient clinic visit for urgent care. An outpatient clinic visit falls within the "Urgently
Needed Services" benefit category. This means that you have been asked to pay less than or equal to 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 copayments for
an outpatient clinic visit (G0463) and an incision and drainage of abscess (10060) provided on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four surgical extractions (D7210 x4) and four bone
replacement grafts for ridge preservation (D7953 x4) provided on April 28, 2021.

You asked the Plan to pay for the surgical extractions and bone replacement grafts. You say that these charges
were due to an accident you had at home when you fell. The Plan denied your request. The Plan says you have
already received the maximum amount of coverage allowed for this type of service. The Plan also says that
these services are not eligible for coverage under your medical 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. These services cannot be covered by Medicare because they are
treatment of the teeth, and are dental in nature. Therefore, we decided that the Plan does not have to pay for the
four surgical extractions (D7210 x4) and four bone replacement grafts for ridge preservation (D7953 x4)
provided on April 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.

You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you have no other means of transportation. The Plan denied your request. The Plan says that this request exceeds the benefit limit.

Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits, they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services rendered on February 20, 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 procedure code 99053 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Billed procedure code 99053 (service[s] provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the medical services rendered on February 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 16, 2021 by a 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 June 16, 2021 by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 13, 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 the claims were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in a skilled nursing facility setting 
and should have been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out-of-network physician services provided to the enrollee
on May 26, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have overage for out-of-network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 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 out-of-network physician services provided to the
enrollee on May 26, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on May 28, 2021.
You asked the Plan to pay for the occlusal guard. You say that the night guard is necessary to protect your teeth because you grind your teeth while you sleep. 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 occlusal guard (D9944) provided on May 28, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from April 16, 2021, to April 19, 2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should be waived because you were admitted to the hospital. 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 a $90 copayment for emergency care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows if the $90 copayment was waived, a $400 inpatient copayment would be applied. 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 visit provided from April 16, 2021, to April 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an x-ray of the right foot. 
 
You asked the Plan to pre-approve an x-ray of the right foot. 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. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an x-ray of the right foot have not been met. Specifically, there is not a doctor's order for the 
requested services. Therefore, we decided that the Plan does not have to pre-approve an x-ray of the right foot.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for immunotherapy (95115) provided on April 27, 2021, by an
out-of-network (OON) provider.

You asked the Plan to pay for immunotherapy. You say that the provider was not aware that they were out-of-network.
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 immunotherapy (95115) provided on April 27,
2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on March 1, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not payable.

The Plan must follow Medicare rules. Medicare rules say that the CP must attempt to consult with the patient's physician within a reasonable time after receiving the consent. If the CP's attempts to consult directly with the physician are not successful, the CP must notify the physician within a reasonable time that he or she is furnishing services to the patient. 

We looked at the file and Medicare rules. In this case, the records do not show that the CP consulted or attempted to consult with the enrollee's PCP. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient mental health services provided on March 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving appropriate acute care in the current hospital setting. An LTACH would not offer any additional services and is therefore not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care.

There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), and periapical x-rays (D0230 x 3) provided on June 19, 2021.
You asked the Plan to pay for the dental services. You say that when you got to your appointment you were not told that they did not accept your insurance. You say that you do not want to pay for the service since you have insurance. You also say that you were not informed that they did not participate with your plan. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services performed out of network 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, dental services received out of network are not among those covered under this benefit. Additionally, the record shows that the provider in this case has written off the charges for the date of service in this case. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), and periapical x-rays (D0230 x 3) provided on June 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis (0037U) rendered by
the out-of-network (OON) provider on August 13, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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 service 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 this service. Therefore, we decided that the Plan
does not have to pay for the targeted genomic sequence analysis (0037U) rendered by the out-of-network
(OON) provider on August 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (88341, 88342) provided on March 26, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says these codes are bundled.

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 codes 88341 and 88342 have a bundled relationship with code 88360 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 services (88341, 88342) provided on March 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 26, 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 March 26, 2021 by a non-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for current procedural terminology (CPT) code 26040 billed for date of service May 12, 2021.
You asked the Plan to pay for CPT code 26040. You say that the medical records provided support the services in dispute. The Plan denied your request. The Plan says the CPT code in dispute was not billed in accordance with Medicare National Correct coding Initiative Policy.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 26040 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of CPT code 26040 have not been met. Therefore, we decided that the Plan does not have to pay for current procedural terminology (CPT) code 26040 billed for date of service May 12, 2021