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

We decided that the Plan has to pay for the routine dental services provided on June 21, 2021.

You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan denied your request. The Plan says that you received care from a provider who has opted out of Medicare, and therefore, the services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the routine dental services have been met. Specifically, the Plan's Evidence of Coverage does not state that you cannot obtain services from a provider who has opted out of Medicare for the supplemental dental policy you enrolled in. Therefore, we decided that the Plan has to pay for the routine dental services provided on June 21, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on July 28, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the genetic testing. You say that the service is medically necessary. 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 service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the genetic testing provided on July 28, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network ear/nose/throat doctor.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says these services are not urgent or emergent, and are available within the 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 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. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network ear/nose/throat doctor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on August 9, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the podiatry services. You say that the denied services on this claim should be considered separate and distinct services. 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. Therefore, we decided that the Plan does not have to pay for the podiatry services provided on August 9, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of residual tooth roots (D7250) for five teeth.
You asked the Plan to pre-approve removal of residual tooth roots. You say that you were not aware that some services are not covered. The Plan denied your request. The Plan says this service is not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve removal of residual tooth roots (D7250) for five teeth.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing provided on April 12, 2021.
You asked the Plan to pay for the testing services. You say that the test is a covered benefit. The Plan denied
your request. The Plan says there was no documented significant interval increase in PSA level.
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx testing is only covered under
certain medical indications.
We looked at the file and the rules. We find that the testing at issue is not supported in the medical record.
Specifically, the medical records provided do not indicate that the enrollee was being considered for a repeat
biopsy due to persistent or elevated cancer-risk factors. Based on this information, we decided that Medicare
rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have
to pay for the ConfirmMDx testing provided on April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventative procedure (D1999), core buildup (D2950), pulp cap (D3120), and crown (D2740), provided on January 12, 2021.

You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan denied your request. The Plan says these are not covered services.

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. Specifically, the services are not listed in the Plan's benefit chart. This means the services are not covered. Therefore, we decided that the Plan does not have to pay for the
preventative procedure (D1999), core buildup (D2950), pulp cap (D3120), and crown (D2740), provided on January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) or pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on August 4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the complete series of intraoral x-rays and to pay more for the periodic oral evaluation and prophylaxis. You say that you have been going to this dental practice for over 20 years, and it is the only practice you have received your dental care from. The Plan denied your request. The Plan says the complete series of intraoral x-rays is not a covered expense under your dental plan. The Plan says that the periodic oral evaluation and prophylaxis were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for these services. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.
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, complete series of intraoral x-rays (D0210) not among those covered under this benefit. The contract says that you are responsible for a 50% coinsurance for a periodic oral evaluation (D0120) and prophylaxis (D1110), plus the difference between the billed amount and allowed amount for the services having been received OON. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) or pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on August 4, 2021 by an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on July 29, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. 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 service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the laboratory work provided on July 29, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on May 30, 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 70496. We find that CPT code 70450 may be eligible for
payment when billed with this code pair. The claim provided does not indicate 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 May 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator (E1390) and durable medical equipment (DME) delivery and set up (A9901), provided on May 11, 2021.

You asked the Plan to pay for the oxygen concentrator and DME delivery and set up. You say that the services should be covered. The Plan denied your request. The Plan says the services are not covered under Medicare.

The Plan must follow Medicare rules. Medicare rules say that oxygen and oxygen equipment, contractors pay a monthly fee schedule amount per beneficiary. Unless otherwise noted below, the fee covers equipment, contents and supplies. Payment is not made for purchases of this type of equipment.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the oxygen concentrator and DME delivery and set up have not been met. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator (E1390) and durable medical equipment (DME) delivery and set up (A9901), provided on May 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on July 21, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the drug testing. You say that the service is medically necessary. 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 service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the drug testing provided on July 21, 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 dermatology services provided on August 11, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the dermatology services. You say that the Plan needs to cover the services because you cannot afford the bills. 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. Therefore, we decided that the Plan does not have to pay for the dermatology services provided on August 11, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 66-year-old female with chronic obstructive pulmonary disease and congestive heart failure. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. In conclusion, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on February 19, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the code remains not supported.
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. The claim provided lists a place of service as an independent laboratory. The medical records provided do not indicate the specimen was obtained at an independent laboratory. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on February 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the abdomen (74178).

You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

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 CT scan. Our reviewer says that the CT scan is not medically necessary. Our physician reviewer found there was no objective findings documented that demand advanced imaging and no history of the course and presentation of the reported pain. There was no documentation of a trial of conservative treatments. 

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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve Computed Tomography (CT) of the abdomen (74178).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920), or pay more for the two problem focused limited oral evaluations (D0140 x2), first intraoral periapical x-ray (D0220), and simple extraction (D7140) provided from April 8, 2021, to May 17, 2021 by an out-of-network (OON) provider

You asked the Plan to pay for the re-cement or re-bond crown, and to pay more for the problem focused limited oral evaluations, first intraoral periapical x-ray, and simple extraction. You say that the Plan's quotes for these services were given to you even though the dental office knew they were not in-network, and the Plan would not pay the amounts. The Plan denied your request. The Plan says your benefits for the re-cement or re-bond crown have been satisfied and the frequency limitation has been exceeded. The Plan also says that the problem focused limited oral evaluations, first intraoral periapical x-ray, and simple extraction were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for these services.

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, recementation is limited to one procedure code every five calendar years. The record shows that you received a re-cement or re-bond crown (D2920) on March 31, 2021 and your recementation benefit has been exhausted. The contract says that you are responsible for a 50% coinsurance for each emergency diagnostic exam and intraoral x-ray, and you are responsible for a 55% coinsurance for extractions that are received OON. You are also responsible for the difference between the billed amount and allowed amount for covered dental services that are received OON. Therefore, we decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920), or pay more for the two problem focused limited oral evaluations (D0140 x2), first intraoral periapical x-ray (D0220), and simple extraction (D7140) provided from April 8, 2021, to May 17, 2021 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam you had on July 29, 2021.
You asked the Plan to waive the copayment for the medical eye exam. You say that you do not agree with this copayment. The Plan denied your request. The Plan says you were charged this copayment 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). Your contract with the Plan clearly says that you must pay a $15 copayment for medical eye exams. You have been asked to pay a $15 copayment for the medical eye exam. 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 medical eye exam you had on July 29, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for testing services provided to the enrollee on August 3, 2021 and billed under code 76705.
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 billing guidelines show a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between codes 76705 and 93976. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when required the appropriate modifiers.
In this case, the claim cannot be paid as billed due to the omission of the required modifier. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for testing services provided to the enrollee on August 3, 2021 and billed under code 76705.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81162, 81295, 81298, 81317, 81402, 81194 and 81309) provided on May 12, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, the claim was billed with the laboratory place of service code and the record indicates that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (81162, 81295, 81298, 81317, 81402, 81194 and 81309) provided on May 12, 2021.