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

We decided that the Plan does not have to pay for the dental services provided on June 8, 2021.
You asked the Plan to pay for the dental services. You say that you've been with this dentist for a year and a half and they are within network. The Plan denied your request. The Plan says the service is not a covered benefit and the provider is not in-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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with PuraPly AM.

You asked the Plan to pre-approve treatment with PuraPly AM. You say that this service is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of this service.

The Plan must follow Medicare rules. Medicare rules say that skin substitutes are covered when you have a skin deficit at least 1.0 square centimeter (cm) in size. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of treatment with PuraPly AM have not been met. Specifically, the medical records show that you do not have a skin deficit of at least 1.0 square cm in size. Therefore, we decided that the Plan does not have to pre-approve treatment with PuraPly AM.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each 
additional 15 minutes (97811) and infrared light therapy (97026) provided February 12, 2021 to February 21, 
2021. 
 
You asked the Plan to pay for the acupuncture and infrared therapy services. You say that the documents will 
indicate medical necessity of the acupuncture services rendered as well as a detailed overview of the enrollee's 
condition and progress. The Plan denied your request. The Plan says these services are not covered under 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan's rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the records show that the services are for shoulder 
pain. Infrared therapy is excluded from coverage. Therefore, we decided that the Plan does not have to pay for 
acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 minutes (97811) and infrared light 
therapy (97026) provided February 12, 2021 to February 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist physician services provided on 
March 8, 2021. 
 
You asked the Plan to waive the copayment for specialist physician services. You say that you did not know 
you would have a copayment. 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 $60 
copayment for specialist physician services with an out-of-network provider.  
 
You have been asked to pay a $60 copayment for specialist physician services. Specialist physician services 
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 specialist physician services provided on March 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound debridement procedure you 
received at an outpatient hospital facility on March 22, 2021. 
 
You asked the Plan to waive the copayment for the wound debridement procedure. You say that you did not 
have a copayment when you received this service before. The Plan denied your request. The Plan says you 
were charged this copayment correctly.  The Plan says that because the allowed amount for this service 
($194.08) 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 $400 
copayment for surgery or other services at an outpatient hospital facility.

You have been asked to pay a $400 copayment for the wound debridement procedure. The wound debridement 
procedure falls within the surgery or other services at an outpatient hospital facility benefit category. This 
copayment applies regardless of how your claims processed in the past. 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 wound debridement procedure you received at an outpatient hospital facility on March 22, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pontic and retainer crowns for a fixed bridge. 
 
You asked the Plan to pre-approve the pontic and retainer crowns for a fixed bridge. You say that you 
developed a bad cavity, the bridge had to be taken off and another crown put on. You say that you will not have 
the work done if it is not covered. The Plan denied your request. The Plan says the services are not covered 
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 pre-approve the 
pontic and retainer crowns for a fixed bridge.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the use of the I-FACTOR allograft as part of spinal 
fusion surgery. 
 
You asked the Plan to pre-approve the use of i-FACTOR allograft. You say that this should be approved. The 
Plan denied your request. The Plan says all other services have been approved. The requested allograft is not 
supported as medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the use of i-FACTOR allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested type of allograft is considered experimental in lumbar fusion 
surgery. More research is needed to support this.

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 use of i-FACTOR allograft have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the use of the I-FACTOR allograft as part of spinal fusion surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on January 5, 2021.
You asked the Plan to waive the copayment for an EGD. You say that you already paid the specialist and
diagnostic radiology copayments and disagree with the additional $200 copayment. The Plan denied your
request. The Plan says the claims were processed correctly, and you 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 $200
copayment for outpatient surgery, including services provided at ambulatory surgical centers.
The medical records show that you received an EGD at an ambulatory surgical center on January 5, 2021. An
EGD is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $200 copayment.
You have been asked to pay a $200 copayment for an EGD. An EGD falls within the outpatient surgery,
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 an EGD provided on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the residential treatment program provided on September 28,
2020 to October 27, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the residential treatment program. You say that you were unable to receive help
"in-network" and you were unable to work through the system in order to save your life. The Plan denied your
request. The Plan says the facility is out-of-network and no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
record shows that subsequent follow-up psychiatric services do not show medical or psychiatric instability,
including suicidal ideation and you were discharged for outpatient care. Therefore, we decided that the Plan
does not have to pay for the residential treatment program provided on September 28, 2020 to October 27,
2020 by an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on May 13, 2021.
You asked the Plan to pay for laboratory services. You say that the enrollee is in a nursing facility and does not have an option on lab services to use. The Plan denied your request. The Plan says this provider is out of network with the Plan and prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on May 26, 2021.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that the request for payment was denied for not a preferred dentist but there is only one dentist in town. The Plan denied your request. The Plan says out-of-network dental services are not covered, and in-network providers were available.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on May 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided on January 2, 2020.
You asked the Plan to pay for the inpatient hospital care. You say that the claim was originally filed with a different company. You also say that this claim should be paid. The Plan denied your request. The Plan says the claim was received past the 12-month time frame. The Plan also says Medicare denies a claim if it is not received by the plan within 12-months or one calendar year from the date when the services were rendered.
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 inpatient hospital care was not filed until April 3, 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 the inpatient hospital care provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the electrocardiogram interpretation and report (93010) provided on 
January 15, 2021. 
 
You asked the Plan to pay for the electrocardiogram interpretation and report. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says that the 
documentation submitted does not support the service 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, the CPT Code Manual definition of 
code 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the electrocardiogram interpretation and report. Our reviewer 
says that CPT code 93010 meets criteria for billing and reimbursement consideration. Our reviewer found 
Medicare does not require a separate report for an electrocardiogram. The provider clearly documented the 
evaluation and management and electrocardiogram were performed, how many leads as well as the results. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the electrocardiogram interpretation and report have been met. Therefore, we 
decided that the Plan has to pay for the electrocardiogram interpretation and report (93010) provided on 
January 15, 2021.  
 
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 pre-approve endodontic therapy, premolar tooth (excluding final restoration) (D3320), endodontic therapy, molar tooth (excluding final restoration) (D3330), pontic - porcelain/ceramic (D6245), and retainer crowns - porcelain/ceramic (D6740).
You asked the Plan to pre-approve endodontic therapy for premolar and molar tooth, pontic and retainer crowns. You say that the services are necessary because you have no molars. The Plan denied your request. The Plan says these services 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 pre-approve endodontic therapy, premolar tooth (excluding final restoration) (D3320), endodontic therapy, molar tooth (excluding final restoration) (D3330), pontic - porcelain/ceramic (D6245), and retainer crowns - porcelain/ceramic (D6740).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transport provided on April 15, 2021.

You asked the Plan to waive the copayment for ambulance transport. You say that you feel like you did not need the services. You also say you did not ask for the ambulance ride, and you should not have to pay at your age. 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 $225 copayment for each one-way ambulance transport. 

You have been asked to pay a $225 copayment for ambulance transport. Ambulance transport falls within the Ambulance Services 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 ambulance transport provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to waive the $35 copayment charged for a specialist visit on April 8, 2021.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on the claim submitted.
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 $35 copayment for specialist services. You have been asked to pay $35 copayment for this copayment. this copayment falls within the specialist services 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 $35 copayment charged for a specialist visit on April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an adult daycare program.
You asked the Plan to pre-approve adult daycare. You say that your doctor suggested getting into an adult
daycare program. The Plan denied your request. The Plan says the denial of authorization for this service is
correct, because this is custodial in nature which is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from
trained medical or paramedical staff, is not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of adult daycare have not been met. Specifically, we find that the services at issue in this case are
considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve an adult
daycare program.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty wheelchair.  

You asked the Plan to pre-approve the requested wheelchair. You say that the scooter you have is for inside the 
house. The Plan denied your request. The Plan says a transport chair has been approved.  

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. The rules state that for equipment to be covered, it must be appropriate and needed 
for use inside the home.   

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a heavy-duty wheelchair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy visits to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the physical therapy visits. You say that you already have an existing relationship with the enrollee, and you are close to her home. The Plan denied your request. The Plan says the provider is out-of-network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available within 30 miles of the enrollee's home who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. The records provided for review do not show that the services at issue are urgent or emergent.
Therefore, we decided that the Plan does not have to pre-approve the physical therapy visits to be provided by an out-of-network (OON) provider.