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

We decided that the Plan does not have to pay for the two core buildups, including any pins when required 
(D2950 x2) and two crowns (D2740 x2) provided on May 25, 2021. 
 
You asked the Plan to pay for the core buildups and crowns. You say that these services were medically 
necessary. The Plan denied your request. The Plan says core buildup is not a covered service. The Plan also 
says that your benefits for the crowns have been satisfied and the frequency limitation has been exceeded. 
 
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, core buildup, including any pins when 
required (D2950) is not among those covered under this benefit. The contract says that crowns are limited to 
two procedure codes per calendar year. The record shows that you received two crowns (D2740 x2) on April 7, 
2021 which were covered by the Plan, and your crowns benefit has been exhausted. Therefore, we decided that 
the Plan does not have to pay for the two core buildups, including any pins when required (D2950 x2) and two 
crowns (D2740 x2) provided on May 25, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for psychotherapy services provided on February 3 to February 24, 2021.
You asked the Plan to pay for psychotherapy services. You say that it is completely unethical and unfair that the Plan did not pay for the telehealth visits at issue. The Plan denied your request. The Plan says that rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that PPO plans must cover all Medicare-covered services out-of-network but may apply higher cost sharing. Medicare has expanded telehealth coverage to allow all providers who may bill Medicare for professional services to be paid for telehealth services. The Plan in this case is a PPO and cannot deny coverage for certain out-of-network services, such as telehealth. The PPO plan is also not allowed to impose prior authorization requirements on covered out of network care. As such, we find that the Plan has not provided any valid denial rationale to support non-payment of this claim. Therefore, we decided that the Plan has to pay for psychotherapy services provided on February 3 to February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for coronavirus testing (U0005) provided on January 21, 2021.
You asked the Plan to pay for coronavirus testing. You say that this should be covered. The Plan denied your request. The Plan says this is not supported.
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 rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We find that CPT code U0005 is not supported in the medical record. Specifically, no medical records documenting this service have been submitted. Based on this information, we decided that Medicare rules for coverage of coronavirus testing have not been met. Therefore, we decided that the Plan does not have to pay for coronavirus testing (U0005) provided on January 21, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 30, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the medical services. You say that you were told that no prior authorization was required for the insertion of tunneled centrally inserted central venous access device (36561) service. You also say that the medical services were rendered to the enrollee in good faith. The Plan denied your request. The Plan says the services provided require prior authorization. The Plan also says that prior authorization has not been 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 medical services provided on April 30, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483, 80307) provided on May 21, 2021, by
an out-of-network (OON) provider.
You asked the Plan to pay for drug testing. You say that this was medically necessary. The Plan denied your
request. The Plan says this was not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for drug testing (G0483, 80307) provided on May 21,
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on September 21, 2020. 
 
You asked the Plan to pay for lab tests. You say that as you do not personally see patients, you are dependent 
on receiving patient information from the ordering provider. The Plan denied your request. The Plan says the 
denial of payment for this testing is correct, because the documentation submitted does not support the Place of 
Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken 
in a nursing facility setting, therefore the POS code 11 - indicating an office setting - is not appropriate for this 
claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. 
Therefore, we decided that the Plan does not have to pay for laboratory testing provided on September 21, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (01270) provided October 7, 2020.
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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. We find that CPT code 01270 is not supported in the medical record. Specifically, the claim was billed with an unspecified diagnosis code. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (01270) provided October 7, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the duplex scans and studies (93922, 93923, 93931, 93979, 93880) provided on July 20, 2020.
You asked the Plan to reduce the copayment for the diagnostic imaging services. You say that these services are all part of one test, and you should owe only the one copayment. The Plan denied your request. The Plan says your cost-sharing was applied correctly. You are responsible for a $160 copayment for each diagnostic radiological service.
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 $160 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or freestanding facility. You have been asked to pay a $485.04 copayment for five diagnostic duplex scan and study services. The provided services are classified as ultrasounds and fall within the Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or freestanding facility 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 reduce the copayment for the duplex scans and studies (93922, 93923, 93931, 93979, 93880) provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture, initial 15 minutes, acupuncture, each additional 15 minutes and infrared light therapy (97026) provided February 19, 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 detailed overview of the enrollee's condition and progress. The Plan denied your request. The Plan says acupuncture is only covered for treatment of chronic low back pain. Infrared therapy is excluded from Medicare coverage.
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 acupuncture services was for the treatment of shoulder pain and infrared therapy is not covered. Therefore, we decided that the Plan does not have to pay for the acupuncture, initial 15 minutes, acupuncture, each additional 15 minutes and infrared light therapy (97026) provided February 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to hold you harmless for the overpayment of the core build up (D2950 x 2), retainer crowns (D6750 x 2), and pontic (D6240) provided on January 28, 2021.
You asked the Plan to hold you harmless for the dental services. You say that you were under the impression that if you changed plans, your new plan benefit amount would start at $0 and not include the $1,250 that had been paid previously. You say that as a result you changed plans. You also say that you should not be responsible for this. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,250 for covered dental services. The Plan also says that the annual maximum benefit has been exhausted.
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 this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the Evidence of Coverage provides a benefit limit of $1,250 for dental benefits. The record shows that the Plan paid this amount twice. The second payment was made in error. Therefore, we decided that the Plan does not have to hold you harmless for the overpayment of the core build up (D2950 x 2), retainer crowns (D6750 x 2), and pontic (D6240) provided on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the discharge medications rendered on April 29, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that codes with a status indicator of M are measurement codes used for reporting purposes only. We looked at the file and Medicare rules. Billed procedure code 1111F (discharge medications reconciled with the current medication list in outpatient medical record [COA][GER]) has a status indicator of M and cannot be used for billing purposes. Therefore, we decided that the Plan does not have to pay for the discharge medications rendered on April 29, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
January 11, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the 
enrollee on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam rendered on May 13, 2021.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was applied 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 $35 copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye, including an annual glaucoma screening for members at high risk.
Review of the file shows that you had an eye exam on May 13, 2021. You have been asked to pay a $35 copayment for these services. These services fall within the Medicare-covered exams to diagnose and treat
diseases of the eye, including an annual glaucoma screening for members at high risk 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 the eye exam rendered on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on July 15, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for out of network physician services provided on July 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurances for a semi-electric hospital bed rental 
(E0260) provided on February 21, March 21, and April 21, 2021; a standard wheelchair rental (K0001) 
provided on March 25 and April 25, 2021; and a general use wheelchair seat cushion (E2601) provided on 
March 25, 2021. 
 
You asked the Plan to waive the coinsurances for a semi-electric hospital bed, a standard wheelchair, and a 
wheelchair seat cushion. You say that the coinsurances are not a fair or appropriate amount for you to pay. The 
Plan denied your request. The Plan says the correct coinsurances were applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 10% 
coinsurance for covered items of durable medical equipment and related supplies.

You have been asked to pay $9.90, or 10% of the Medicare-allowed charge of $99.00, for each of 3 dates of 
service for a semi-electric hospital bed; to pay $5.40, or 10% of the Medicare-allowed charge of $54.00, for 
each of 2 dates of service for a standard wheelchair; and to pay $5.81, or 10% of the Medicare-allowed charge 
of $58.10, for a wheelchair seat cushion. The items at issue fall within the "Durable medical equipment and 
related 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 coinsurances for a semi-electric 
hospital bed rental (E0260) provided on February 21, March 21, and April 21, 2021; a standard wheelchair 
rental (K0001) provided on March 25 and April 25, 2021; and a general use wheelchair seat cushion (E2601) 
provided on March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the 200 test strips (A4253 x 4), 200 lancets (A4259 x 2), and the 
control/calibration solution (A4256 x 3) provided from February 16, 2021, through May 6, 2021. 
 
You asked the Plan to pay for the amount of test strips/lancet/solution provided. You say that this was correctly 
billed based on the order from the treating physician. The Plan denied your request. The Plan says that the 
submitted Durable Medical Equipment Order does not clearly indicate the number of items/units for the billed 
item. This means that the order does not support the number of items provided. 
 
The Plan must follow Medicare rules. Medicare rules say that DME providers are required to provide a copy of 
the physician order to justify billed items. The rules say that for insulin-using enrollees, up to 300 strips/lancets 
per three-month period is covered. 
 
The Plan's rationale that the number of units provided are not noted on the order is not correct. The order 
clearly indicates that, since the enrollee is testing twice per day, that 200 strips/lancets are necessary per three-
month period. This exactly corresponds to the number of units of each code billed. In addition, the testing is 
well within the limit for usual utilization for an enrollee who uses insulin, which is also documented on the 
order. There is no valid basis provided for denial of payment of this claim. Therefore, we decided that the Plan 
has to pay for the 200 test strips (A4253 x 4), 200 lancets (A4259 x 2), and the control/calibration solution 
(A4256 x 3) provided from February 16, 2021, through May 6, 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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve revascularization surgery for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says that it is unclear if there are symptoms affecting everyday life. 
 
The Plan must follow Medicare rules. The rules say that percutaneous transluminal angioplasty (PTA) is 
covered when used under certain conditions. 
 
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 surgery. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation supports the medical necessity of the intervention in question. The enrollee has 
documented bilateral lower extremity lifestyle limiting claudication, documented absent pulses bilaterally, and 
is status post intervention on the left lower extremity with documentation of improvement. 

At the time of angiography, the enrollee was demonstrated to have a focal area of high grade stenosis in the 
right superficial femoral artery (SFA) that might be amenable to endovascular treatment. As the enrollee 
already had the left side treated, he is unlikely to appreciate a substantial improvement in walking distance if 
the right side is left unaddressed. 
 
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 surgery have been met. Therefore, we decided that the Plan has to pre-
approve revascularization surgery 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on September 28,
2020.
You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item at issue is a medical necessity for
the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain relevant medical records which support medical necessity for the supplies provided
in this case. The medical records submitted do not discuss the supplies at issue. The record shows that the Plan
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the
Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on September 28, 2020.