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

We decided that the Plan does not have to pre-approve porcelain fused to high noble metal crowns (D2750) for teeth #25, #26, #20 and #21.
You asked the Plan to pre-approve the crowns. You say that these crowns are necessary, and you do not understand why this type of crown is not covered. The Plan denied your request. The Plan says the specific type of crown requested 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. Procedures, items and services are assigned specific and unique codes based on the definition of the item/service/procedure provided. The Plan does cover some crowns, including (but not limited to) porcelain fused to predominantly base metal (D2751), porcelain fused to noble metal (D2752) and porcelain/ceramic (D2740). However, the particular type of crown requested, which uses high noble metal and is described with code D2750, is not among those listed as covered by this benefit. Therefore,
we decided that the Plan does not have to pre-approve porcelain fused to high noble metal crowns (D2750) for teeth #25, #26, #20 and #21. You may wish to talk to your provider about requesting a crown that is eligible for coverage under your dental benefit and is listed in the contract.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided on June 22, 2020.
You asked the Plan to pay for the laboratory test. You say that payment in full is required for clinical laboratory testing used to diagnose COVID. You say that failure to make payment is in violation of the law. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory test provided on June 22, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient mental health services rendered from April 6, 2021, to April 29, 2021.
You asked the Plan to waive the coinsurance for these services. You say that you were advised that the provider was in-network. The Plan denied your request. The Plan says the coinsurance 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 50% of the total allowed amount per provider, per day for each out-of-network Medicare-covered individual visit with a psychiatrist or different type of specialist.
Review of the file shows that you received outpatient mental health services from an out-of-network provider on April 6, 2021 to April 29, 2021. You have been asked to pay 50% of the total allowed amount for these services. These services fall within the out-of-network Medicare-covered individual visit with a psychiatrist or different type of specialist 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. The Plan reviewed your call history and found no record of contact where you inquired about the network status of this provider. Therefore, we decided that the Plan does not have to waive the coinsurance for the outpatient mental health services rendered from April 6, 2021, to April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid (V5261) received December 22, 2020, from the out-of-network provider.

You asked the Plan to pay for the hearing aid. You say that this hearing vendor was more convenient for you to reach. The Plan denied your request. The Plan says hearing aids ordered through providers other than in-network Plan hearing vendors are not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when ordered through in-network Plan hearing vendors. 

We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid (V5261) received December 22, 2020, from the out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for electroencephalogram (EEG) (95955) nerve conduction studies (95908) limited needle electromyography (95885) provided November 12, 2019.
You asked the Plan to pay for neuromonitoring services. You say that your services were ordered by the enrollee's in-network surgeon and provided in an in-network facility that has established your services as the standard of care for the enrollee's surgical procedure. The Plan denied your request. The Plan says documentation does not support service billed. Documentation supports electrical stimulation of the pedicle
screws. Pedicle testing would not be reported as nerve conduction studies. Therefore, this procedure cannot be confirmed as performed.
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 95955 is electroencephalogram (EEG) during nonintracranial surgery (carotid surgery), CPT 95908 is nerve conduction studies, for 3-4 studies, and, CPT 95885 is limited needle electromyography, per each extremity with related paraspinal areas when performed, one with nerve conduction, amplitude and latency/velocity study; (listed separately in addition to code for primary procedure). 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 neuromonitoring services. Our reviewer says that the records do not support the CPT codes in dispute. Our physician reviewer found no documentation was found to support CPT 95955 cannot be performed continuous. Therefore, CPT 95955 would be the correct code to report in this case. The records do not include documentation of nerve conduction studies, for 3-4 studies. Per the technical report, documentation supports electrical stimulation of the pedicle screws. Pedicle testing would not be reported as nerve conduction studies. Therefore, this procedure cannot be confirmed as performed. CPT 95885 is done with nerve conduction studies. The documentation does not support that nerve conduction studies were performed therefore, this procedure would not be covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for electroencephalogram (EEG) (95955) nerve conduction studies (95908) limited needle electromyography (95885) provided November 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the arm lesion incision and drainage rendered on October 27, 2020.

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 claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. 

We looked at the file and Medicare rules. The file shows that procedure code 23930 (incision and drainage, arm lesions) was billed with the LT modifier to show a left-sided procedure; however, the claim was billed with diagnosis code Z96.621 for the right elbow. This diagnosis code is not appropriate for the left-sided procedure. Therefore, we decided that the Plan does not have to pay for the arm lesion incision and drainage rendered on October 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to build his strength for surgery. The Plan denied your request. The Plan says the enrollee's care is routine, and he does not need a team of providers.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for congestive heart failure. His medical conditions are stable. The complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
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: ER
Decision: Favorable

We decided that the Plan has to pay for the emergency department visit provided on March 26, 2021.
You asked the Plan to pay for the emergency department visit (99281). You say that the Plan should pay this claim. The Plan denied your request. The Plan says that the claim was paid and charged to the enrollee's copay.
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 99281 is emergency department visit for the evaluation and management of a patient. We find that CPT code 99281 was covered by the Plan. The Plan has incorrectly designated the Medicare Allowed amount to the enrollee's copayment. The enrollee has no copayment for Emergency Care. Therefore, we decided that the Plan has to pay the provider the Medicare Allowed amount for the emergency department visit provided on March 26, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 14, 2020, to November 17, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says SNF care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that the enrollee received 100 days of SNF care during the benefit period from August 13, 2020, to January 5, 2021. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from November 14, 2020, to November 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee is functioning at her physical baseline.
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 the enrollee is able to ambulate up to 100 feet using a walker with contact guard assistance. She is able to navigate steps and transfers with contact guard assistance and can perform self-care tasks. She has been treated for a urinary tract infection with urinary retention requiring placement of a Foley catheter. She has remained medically stable. Although further rehab services would be appropriate to improve function, the intermittent skilled services can be provided at a lower level of care. Therefore an admission to a SNF is not medically necessary. 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 a skilled nursing facility (SNF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a
participating provider on March 10, 2021.

You asked the Plan to waive the copayment for an outpatient surgery. You say that this was preventative. You
say that there should be a $0 copayment. The Plan denied your request. The Plan says the correct copayment
has 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 $350
copayment for outpatient surgery/ambulatory surgical center.

You have been asked to pay a $350 copayment for an outpatient surgery. The endoscopy that was provided was
diagnostic in nature; therefore, the correct copayment has been applied. Outpatient surgery falls within the
outpatient surgery/ambulatory surgical center 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 outpatient surgery provided by a participating provider on March 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the WATS 3D Biopsy services provided on January 7, 2021.

You asked the Plan to pay for the WATS 3D Biopsy 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 must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the WATS 3D Biopsy services.

Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has Barrett's esophagus. The medical literature and clinical practice guidelines do not support the clinical utility of testing with computer-assisted immunohistochemistry to predict cancer. Also, there is no documentation in the pathology report regarding the need for the special stain. The documentation does not indicate that the enrollee has a diagnosis/condition that meets criteria for the rendered 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 the WATS 3D Biopsy services have not been met. Therefore, we decided that the Plan does not have to pay for the WATS 3D Biopsy services provided on January 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient appears to have only required short-term acute care to complete treatment which could have been safely performed at the short-term acute care facility. The patient does not require services at the LTACH that were not already available at the current facility. 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 LTACH services have not been met. Specifically, the enrollee wor reasonable. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.as receiving medically necessary services in an acute inpatient hospital. This means LTACH care is not medically necessary
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telehealth visit (99308) provided January 7, 2021.

You asked the Plan to pay for the telehealth visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a required modifier.

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 99308 is not supported in the medical record. Specifically, telehealth services must be reported using modifier 95. Based on this information, we decided that Medicare rules for coverage of the telehealth visit have not been met. Therefore, we decided that the Plan does not have to pay for a telehealth visit (99308) provided January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation to be provided by an out-of-network provider.
You asked the Plan to pre-approve the consultation. You say that you are appealing the Plan's decision because of your medical conditions. You state you have a severe infection in your kidneys. The Plan denied your request. The Plan says the services are available in-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 the consultation to be provided by an out-of-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve additional routine transportation trips. The Plan denied your request. The Plan says the benefit only allows for 24 one-way transportation trip per calendar year and the member has used 25 one-way transportation trips for this calendar year.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve crowns and core build-up (D2740, D2950).
You asked the Plan to pre-approve the crowns and core build-up. You say that the dental services are medically necessary. The Plan denied your request. The Plan says that the records do not support that coverage criteria has been et.
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. The Plan covers the crowns and core build-up when the services are medically necessary and reasonable. 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 crowns and core build-up. Our reviewer says that the requested services are medically necessary. Our physician reviewer found a review of the patient's dental record and radiographs indicate that teeth 7, 8, 9, and 10 have significant coronal breakdown. The core buildup and crown restorations are medically reasonable and necessary to restore these teeth to adequate function. 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 crowns and core build-up have been met. Therefore, we decided that the Plan has to pre-approve crowns and core build-up (D2740, D2950).
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.