Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) scan of the thoracic spine (72146) and an MRI scan of the lumbar spine (72148).

You asked the Plan to pre-approve these services. You say that the MRI services requested are medically necessary. The Plan denied your request. The Plan says that the MRI services requested are not medically necessary as there is no documentation of neurological deficits or trial and failure of six weeks of conservative therapy including physical therapy.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 these services. Our reviewer says that the MRI services are medically necessary. Our physician reviewer found that based on symptomatology and exam findings, the MRI services requested are indicated and reasonable.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) scan of the thoracic spine (72146) and an MRI scan of the lumbar spine (72148). 

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 a core buildup, including any pins when required (D2950). You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this service is 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. 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 a core buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous surgery (D4261 x 2) and the bone replacement graft (D4263 x 2) provided.

You asked the Plan to pay for the dental services. You say that you have a dental benefit limit of $2,000. You say that the benefit is for all covered services. You also say that you received treatment from this provider in the past and partial payment was made.The Plan denied your request. The Plan says the osseous surgery is not listed as a covered service. The Plan says that the bone replacement graft is not listed as a covered service either. The Plan also says that any services not listed 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the osseous surgery (D4261 x 2) and the bone replacement graft (D4263 x 2) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit provided July 13,
2020.
You asked the Plan to waive the copayment for the office visit. You say that you had a surgical injection
procedure on 6/30/2020 and the follow up visit on 7/13/20. You have never paid for a follow-up after a
procedure before as it was always part of the procedure. The Plan denied your request. The Plan says the claim
was processed and the correct copayment was applied per the Evidence of Coverage.
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 physician specialist services (including surgery second opinion, Medicare covered telehealth or
urgently needed services.
You have been asked to pay $35 copayment for the office visit. The office visit 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 the outpatient office visit provided July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 21, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says his plan
allows for out-of-network coverage for emergency services or when there are no in-network providers
available. There are in network providers available.
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
physician's services. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for physician's services provided on July 21, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from June 16, 2020, through August 25, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says prior authorization is needed to allow coverage of certain services such as elective hospital admissions, skilled nursing facility admissions, outpatient therapy and any out of network care. It is your responsibility to be sure that prior authorization is obtained and the services are approved by the plan to be eligible for coverage.
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 psychotherapy services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided from June 16, 2020, through August 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on August 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you do not agree with this denial. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also 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 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 has network providers available who can provide 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 lab work provided on August 13, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis and sleeve provided to the enrollee on July 14, 2020.You asked the Plan to pay forthese items. You say that these items were medically necessary for the enrollee.The Plan denied your request. The Plan says that without a face-to-face encounter, the ordering physician couldn't gather the information associated with diagnosing, treating, or managing the clinical condition for which the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) were ordered.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 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 forthe knee orthosis and sleeve provided to the enrollee on July 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on June 29, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or
emergent, nor were they approved in advance.
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
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for laboratory services provided on June 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a behavioral health inpatient admission provided from August 11, 2020, through August 13, 2020.You asked the Plan to pay for the behavioral health inpatient admission. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.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 Plandid not pre-approve the behavioral health inpatient admission.We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a behavioral health inpatient admission provided from August 11, 2020, through August 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance services provided on July 2, 2020.
You asked the Plan to pay for the air ambulance services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered were not medically necessary.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 pay for the air ambulance services. Our reviewer says that the documentation does not support that the services rendered were medically reasonable or necessary. Our physician reviewer found the enrollee had atrial fibrillation with rapid ventricular response (on a diltiazem drip) and with an acute non-ST myocardial infarction. Air ambulance services were provided on July 2, 2020 for a higher level of cardiology care. The documentation supports that the enrollee suffered from an illness or injury that contraindicated transportation by any means other than ambulance (acute myocardial infarction with rapid atrial fibrillation).
However, the documentation does not support that the enrollee's condition was such that the time needed to transport the patient by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the patient's health. Therefore, the documentation does not support that the enrollee met criteria for the services rendered. 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 air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance services provided on July 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services provided on May 20, 2020.You asked the Plan to pay forguided tissue regeneration (D4266), surgical placement of implant body (D6010), and bone graft (D6104).You say that the Plan should pay this claim.The Plan denied your request. The Plan says the procedures are not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe dental services provided on May 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged evaluation & management (EM) service provided on October 1, 2020 billed with code 99358. You asked the Plan to pay for the prolonged EM services. You say that the notes provided supports payment for these codes. The Plan denied your request. The Plan says 99358 is not appropriate when all time spent for EM services in on unit/floor. 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 99358 is Prolonged evaluation and management service before and/or after direct patient care; first hour. 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 pay for the prolonged EM services. Our reviewer says that the billed code is not supported. Our physician reviewer found the records do not include documentation to support prolonged service was not additional unit/floor time in the hospital setting. Per CPT guidelines, "CPT 99358 is used when a prolonged service is provided that is neither face-to-face time in the office or outpatient setting, nor additional unit/floor time in hospital or nursing facility setting during the same session of an evaluation and management service and is beyond the usual physician or other qualified health care professional service time". Documentation does not support the use of CPT 99358. 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 prolonged EM services have not been met. Therefore, we decided that the Plan does not have to pay for the prolonged evaluation & management (EM) service provided on October 1, 2020 billed with code 99358.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 10, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined thatthese services are not urgent or emergent, nor were they approved in advance.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 Plandid not pre-approve the physician's services.We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services (11056) provided March 4, 2020.
You asked the Plan to pay for the podiatry services. You say that the services were medically necessary. The Plan denied your request. The Plan says this is a duplicate claim.
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 11056 is not supported in the medical record. Specifically, records show this CPT code was already paid on August 28, 2020. Based on this information, we decided that Medicare rules for coverage of the podiatry services have not been met. Therefore, we decided that the Plan does not have to pay for podiatry services (11056) provided March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (93010) provided on July 5, 2020.
You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says there is no documentation for an interpretation
by the rendering provider.
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 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 pay for the electrocardiogram. Our reviewer says
that CPT code 90310 does not meet criteria for billing or reimbursement consideration. Our physician reviewer
found there is no documentation in the provided records of a physician's interpretation, note or signature with
regard to the electrocardiogram.
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 electrocardiogram have not been met. Therefore, we decided that the Plan
does not have to pay for the electrocardiogram (93010) provided on July 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the 2 fillings provided on August 10, 2020.
You asked the Plan to reimburse you for the fillings. You say that you cannot afford to pay for these services. You say that full payment would cause a financial hardship for you. The Plan denied your request. The Plan says there is an allowance of $150 for covered dental services. The Plan says that the dental allowance has been exhausted. The Plan says you are responsible for any amount above the dental coverage limit.
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 dental allowance of $150 has been exhausted.

Therefore, we decided that the Plan does not have to reimburse you for the 2 fillings provided on August 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pay forECG services provided to the enrollee on August 15, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysno corrected claim was received.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 99285 and 93010 is not supported in the medical record. Specifically, this was billed with a secondary-only diagnosis code as the primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forECG services provided to the enrollee on August 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean extraction (D7140).You asked the Plan to pre-approvethe extraction. You say that your teeth are breaking off, which is causing constant infections and other severe medical problems.The Plan denied your request. The Plan says this service is not covered under your plan.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-approvean extraction (D7140).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network physician services provided on August 20, 2020.You asked the Plan to pay forthis service. 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 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 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. 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 forout of network physician services provided on August 20, 2020.