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

We decided that the Plan does not have to pay for the removable prosthodontic procedures (D5899) or pay
more for the complete mandibular denture (D5120) provided on September 14, 2021.
You asked the Plan to pay for the removable prosthodontic procedures and to pay more for the complete
mandibular denture. You say that these services were needed. The Plan denied your request.
The Plan says the complete mandibular denture (D5120) is a covered benefit, but you had already reached your
$1,000 annual maximum in this dental visit. The Plan also says that the unspecified removable prosthodontic
procedure (D5899) is not covered under your contract under any normal circumstances.
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 unspecified removable
prosthodontic procedure (D5899) is not among those covered under this benefit. The contract says that the Plan
offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit
maximum has been met, you are responsible for the full charges of any additional dental services. The record
shows that you met the annual maximum benefit while processing this claim for the September 14, 2021 date
of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not
have to pay for the removable prosthodontic procedures (D5899) or pay more for the complete mandibular
denture (D5120) provided on September 14, 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 you do 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 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: Drugs
Decision: Unfavorable

We decided t
hat the Plan does not have to pay for the self-administered drugs provided from July 5, 2021, to 
July 6, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the self-administered drugs are not 
covered under your Medicare Part B benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from July 5, 2021, to July 6, 2021.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (procedure code 72170) provided to the
enrollee on August 20, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says a modifier was not used to represent the services as separate and distinct.
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 72170 is "Radiologic examination, pelvis; 1 or 2 views."
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 services. Our reviewer says that the services at issue in
this case were not supported by the medical records. Our reviewer found CPT 72170 has a bundled relationship
with CPT 73502, which was also performed during the same session on August 20, 2021. A modifier is
allowed to unbundle these services, providing the medical records support the use of the acceptable
modifier. In this case, an acceptable modifier was not appended to CPT 72170 26 when it was billed to the
health plan, therefore, it is not eligible for reimbursement consideration.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for radiology services (procedure code 72170) provided to the enrollee on August 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hereditary cancer panel for cancer screening (CPT code(s): 81295, 81408, 81403, 81298, 81407) provided to the enrollee on February 11, 2021.
  
You asked the Plan to pay for the testing. You say that this service was denied as experimental in error. The Plan denied your request. The Plan says genetic screening test is not a covered benefit. 
 
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, the testing, 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 hereditary cancer panel for cancer screening (CPT code(s): 81295, 81408, 81403, 81298, 81407) provided to the enrollee on February 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for general health panel testing provided on September 28, 2021.

You asked the Plan to pay for general health panel. You say that you are appealing with supporting 
documentation. The Plan denied your request. The Plan says this test is not covered by Medicare.

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, general health panel, is a Medicare excluded test that was requested for 
screening purposes. Medicare does not cover this test. Therefore, we decided that the Plan does not have to pay 
for general health panel testing provided on September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal orthotic device (E1399).

You asked the Plan to pre-approve the occlusal orthotic device. You say that it is very difficult and painful for you to eat, and you are losing weight. The Plan denied your request. The Plan says occlusal orthotic devices are not covered by Medicare for your medical condition.

The Plan must follow Medicare rules. Medicare rules say that oral occlusal appliances used to treat temporomandibular joint (TMJ) disorders are considered to be dental devices that will be denied as non-covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occlusal orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve an occlusal orthotic device (E1399).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on April 21,
2021.
You asked the Plan to pay for the therapeutic activities. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services are not payable 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, the CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve functional performance), each 15 minutes.
We find that CPT code 97530 is not supported in the medical record. Specifically, the documentation shows
that this service was performed by an occupational therapist assistant in a home health or hospice setting. There
is a more appropriate code to be billed for the services rendered. Based on this information, we decided that
Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan
does not have to pay for the therapeutic activities coded 97530 provided on April 21, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that you need more time in a SNF to get more 
strength in your legs. The Plan denied your request. The Plan says 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 pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for continued SNF services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance transportation provided on August 9, 202,1 and August 30, 2021.
You asked the Plan to waive the copayments for ambulance transportations. You say that you needed transportation to the emergency hospital because of a prior outpatient surgery. The Plan denied your request. The Plan says the proper copayments have been 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 $265 copayment for each covered, one-way ambulance trip by ground or water.
You have been asked to pay a $530 copayment for the ambulance transportations. Ambulance transportation falls within 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 copayments for the ambulance transportation provided on August 9, 2021 and August 30, 2021.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on August 12,
2021.
You asked the Plan to pay for the CT scan. 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 CPT code. The file shows that CPT code 70450 was billed with code 70496. We looked at the file and the rules. We find that CPT code 70450 may be eligible for payment when billed with this code pair. The claim information does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on August 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an x-ray of the knee provided on March 2, 2020.  You asked the Plan to waive the copayment for the x-ray. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $40 copayment for Outpatient diagnostic tests and therapeutic services and supplies.        You have been asked to pay a $40 copayment for the x-ray. X-rays 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 copayment for an x-ray of the knee provided on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on August 10, 2021.

You asked the Plan to waive the copayment for the urgent care visit. You say that you were told there would be no cost for the coronavirus testing. 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 $50 copayment for urgently needed services at an urgent care center.

You have been asked to pay a $50 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The record shows you were charged for the visit. 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 urgent care visit provided on August 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on April 29, 2021.  

You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.
  
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 
  
The ambulance company did not provide transport services on April 29, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visit (99336) provided on April 29, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for domiciliary or rest home visit. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

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 domiciliary or rest home visit (99336) provided on April 29, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 12, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that the enrollee presented to the emergency room for treatment because that is the only source of health where she was currently located. 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 office visit provided on May 12, 2021, by an out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from August 29, 2021, to September 4, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you feel you should not be responsible for the copayment due to a previous outpatient surgery. 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 $325 copayment per day, per admission for days 1-6 for covered in-network hospital stays. You have been asked to pay a $524.23 copayment for the inpatient hospital stay. The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The record shows that you met the maximum out-of-pocket amount with this claim. 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 inpatient hospital stay provided from August 29, 2021, to September 4, 2021.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the comprehensive periodontal evaluation (D0180). We decided that 
the Plan does not have to pay for the periodontal maintenance (D4910) and complete series of intraoral x-rays 
(D0210). 

You asked the Plan to pay for the comprehensive periodontal evaluation (D0180), periodontal maintenance 
(D4910), and complete series of intraoral x-rays (D0210) provided on September 9, 2021. You say that in the 
book it says you are covered for two exams. The Plan says that these services are not covered under your plan.

We decided that the Plan has to pay for the comprehensive periodontal evaluation (D0180). 

The Plan follows Medicare rules. Medicare rules say that the health plan must provide you with a clear and 
accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under 
your plan contract including applicable conditions and limitations and any other conditions associated with the 
use or receipt of the benefits. 

The record shows that you received a comprehensive periodontal evaluation (D0180) on September 9, 2021. 
The 2021 Evidence of Coverage (EOC) states that you are limited to two exams and cleanings per year. The 
EOC does not specifically state exactly which types of exams are covered under your dental benefit, this 
specific type of exam is not listed as an exclusion, and the records do not show that you had exhausted your 
exams benefit prior to this date of service. You reasonably believed this comprehensive periodontal evaluation 
(D0180) would be covered because exams are listed as a covered benefit twice per year. Therefore, we decided 
that the Plan has to pay for the comprehensive periodontal evaluation (D0180). 

We also decided that the Plan does not have to pay for the periodontal maintenance (D4910) and 
complete series of intraoral x-rays (D0210).

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, periodontal maintenance (D4910) and 
complete series of intraoral x-rays (D0210) are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for the periodontal maintenance (D4910) and complete series of 
intraoral x-rays (D0210).

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.