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

We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) and complete
denture - mandibular (D5120) provided February 25, 2021.

You asked the Plan to pay for the complete upper and lower denture. You say that you need your dentures
replaced. The Plan denied your request. The Plan says dentures are not covered under your benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the 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
complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided February 25,
2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834, 90837) provided on
September 30, 2020, to January 21, 2021.

You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for psychotherapy
services have not been met.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834, 90837)
provided on September 30, 2020, to January 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the inherited cardiovascular risk panel provided on January
12, 2021.

You asked the Plan to pay for the inherited cardiovascular risk panel. You say that this sample is taken by the
patient in their home. It was ordered by the treating physician and should be covered. The Plan denied your
request. The Plan says Medicare does not cover cardiovascular risk panels for any reason.

The Plan must follow Medicare rules. Medicare considers genetic testing medically necessary to establish a
molecular diagnosis of an inheritable disease only when the results will directly impact the treatment of the
enrollee's condition.

We looked at the file and Medicare rules. There are no medical records from the ordering physician which
indicate that the results of this testing will directly impact the enrollee's treatment. Based on this information,
we decided that Medicare rules for coverage of the inherited cardiovascular risk panel have not been met.
Therefore, we decided that the Plan does not have to pay for the inherited cardiovascular risk panel provided on
January 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 17, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file, the Plan's contract and Medicare rules. If a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS codes must be submitted for the panel. If the laboratory assays genes in serial, then the laboratory must submit claims for genes individually. The order by the treating clinician must reflect whether the treating clinician is ordering a panel or single genes, and additionally, the patient's medical record must reflect that the service billed was reasonable and necessary. 

When more than two codes from this list are submitted for the same beneficiary on the same date of service, the claims processing system will reject every code submitted after the first two services. However, if a lab runs more than two distinct procedural services from this list on a single date of service, then the lab must use the 59 modifier with each additional service billed as an attestation that it is a distinct procedural service. 

In this case, the medical records provided do not confirm that the labs were billed correctly. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided on April 3, 2020.

You asked the Plan to pay for the hospital services. The Plan denied your request. The Plan says Medicare
denies a claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 calendar year
from the date the services were furnished.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.

The record shows that a claim for the hospital services was not filed until July 28, 2021. This means that more
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that
the Plan does not have to pay for hospital services provided on April 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81404, 81407, 81408, and 81479) 
provided on January 19, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (81404, 81407, 81408, and 81479) provided on January 19, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve blepharoplasty, upper eyelid; with excessive skin weighting down 
lid (CPT code 15823), for the enrollee.  
You asked the Plan to pre-approve the service. You say that blepharoplasty repair is medically necessary with 
approved ptosis repair. You state blepharoplasty coverage was denied because the eyelid skin is not touching 
the eyelashes in the picture. You state the enrollee is elevating their brows in the photographs, providing the 
"taped" eyelid photos mentioned in the denial letter. You state when the eyelids are elevated with ptosis repair, 
the redundant eyelid skin will bury the eyelashes. You state the frontalis muscle (brow elevator) will relax, 
exacerbating the eyelid/lash contact. and this will necessitate an additional blepharoplasty surgery, incurring 
additional cost and risk. The Plan denied your request. The Plan says that the photographs submitted with the 
medical records do not show the enrollee's eyelids having true ptosis (sagging) when excessive skin is elevated 
by taping or otherwise retracted; per Medicare criteria. The Plans states they did attempt to obtain these 
records, but did not receive the requested photographs; therefore, this is considered not medically necessary 
and is denied.  

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 service. Our physician reviewer 
found LCA A52837 states that blepharoplasty may be considered reconstructive when performed to correct 
visual impairment caused by dermatochalasis. It is recognized that brow ptosis repair, in addition to 
blepharoplasty and/or blepharoptosis repair, may be necessary in some cases to provide an adequate functional 
result. The visual fields demonstrate a significant loss of superior visual field and potential correction of the 
visual fields by the proposed procedures. Adequate photographs are submitted. 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 service have been met. Therefore, we decided that the Plan has to pre-approve blepharoplasty, upper eyelid; 
with excessive skin weighting down lid (CPT code 15823), for the enrollee.   

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81291, 81407, 81408, 81479, and 81439) provided on August 20, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services (81291, 81407, 81408, 81479, and 81439) provided on August 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal x-ray provided on May 7, 2021.
You asked the Plan to pay for the x-ray services. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. We find that CPT code 74018 was billed with 74240. Code 74018 is separately payable when billed with a modifier. The claim provided does not show the code at issue was billed with an appropriate modifier. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal x-ray provided on May 7, 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a 
reasonable expectation that the enrollee 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: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that that you no longer require daily skilled services and the continuation of SNF is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided any medical records for review. Without medical records we are unable to substantiate the Plan's medical necessity denial. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the abutment supported crowns provided on May 26, 2021.

You asked the Plan to pay for the abutment supported crowns. You say that these are replacement teeth to match the new crowns. The procedure was already done to stop damaging teeth and fix the pain. The Plan denied your request. The Plan says abutments are 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 abutment supported crowns provided on May 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services 
provided from January 1, 2021, to February 28, 2021. 
 
You asked the Plan to waive the copayment for the SNF services. You say tht You did not provide an argument 
in your appeal, you simply provided a copy of the outstanding invoice from the SNF. The Plan denied your 
request. The Plan says this copayment was charged 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 $0 copayment for days 1-20, and a $50 copayment per day for days 21-100 for skilled nursing 
facility services.  
 
Records show that the enrollee was admitted to the SNF on December 30, 2020, and he remained there until 
April 5, 2021, for a total of 96 days.  In accordance with the contract, the enrollee was not charged a copayment 
for days 1-20 (December 30, 2020, to January 18, 2021.)  For the remaining 13 days of January, the enrollee 
was charged a $50 copayment per day, for a total of $650.  The enrollee continued his stay in the SNF in 
February. However, he hit his $999 annual out-of-pocket maximum as of February 8.  That is why he is only 
being charged $349 for the remaining SNF services he received (January bill $650 + February bill $349 = 
$999). 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 skilled nursing facility (SNF) 
services provided from January 1, 2021, to February 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies (99072) provided November 5, 2020.

You asked the Plan to pay for the supplies. You say that the items were medically necessary. The Plan denied your request. The Plan says the billed code is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 99072 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, this code has a status of "B" which means payment is bundled with payment for the primary service. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for additional supplies (99072) provided November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit provided on June 16, 2021 by an out-of-network
(OON) provider.
You asked the Plan to pay for the home visit. You say that a referral was unable to be obtained since the patient
had not seen a provider in a long time. 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 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 services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the home visit provided on June 16, 2021 by an out-of-network
(OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost sharing for the office visit you had with an out-of-network internal medicine doctor on April 6, 2021, lab services and the computed tomography (CT) scan you had an an out-of-network hospital on April 27, 2021, and ophthalmology services you had with an out-of-network eye doctor on May 17, 2021.
You asked the Plan to reduce the cost sharing for the out-of-network services. You say that all of these providers told you that they accepted your insurance. The Plan denied your request. The Plan says because none of these providers is in-network with your specific plan, the correct cost sharing was assessed.
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 $750 deductible for out-of-network services. After this deductible is met, you pay 50% coinsurance for out-of-
network care. You have been asked to pay a $750 deductible for the out-of-network services. After this deductible was met, you were asked to pay 50% coinsurance for the remainder of the bills for these services. The Plan has confirmed that all three of these providers are out-of-network with your plan. 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 office visit you had with an out-of-network internal medicine doctor on April 6, 2021, lab services and the computed tomography (CT) scan you had an an out-of-network hospital on April 27, 2021, and ophthalmology services you had with an out-of-network eye doctor on May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services you received on April 27, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that you are on a heart monitor and you received a call stating that you needed to go to the emergency room. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this ambulance transport ($228.71) 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 $250 copayment for ambulance services. 

You have been asked to pay a $250 copayment for the ambulance services. This copayment applies regardless of the reason for the transport. 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 ambulance services you received on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on February 22, 2021.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.
We looked at the file and Medicare rules. The file does not show that the services provided were either emergent or urgent, renal dialysis, or pre-approved care. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for the physician services provided on February 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency transportation, wheelchair van  
(A0130, S0209) provided on May 17, 2021. 
 
You asked the Plan to pay for non-emergency transportation, wheelchair van. The Plan denied your request. 
The Plan says wheelchair van (chair car) transportation is not covered by Medicare even if provided by an 
ambulance company. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for non-emergency transportation, wheelchair van (A0130, S0209) provided 
on May 17, 2021.