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

We decided that the Plan has to pay for the surgical services described by current procedural terminology (CPT) codes 15002 and 15003 provided on October 8, 2020.

You asked the Plan to pay for CPT codes 15002 and 15003. You say that the medical records support the billing of CPT codes 15002 and 15003 provided on October 8, 2020. The Plan denied your request. The Plan says that the medical records do not support the billing of CPT codes 15002 and 15003 provided on October 8, 2020.

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 15002 is Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children. The CPT Code Manual definition of code 15003 is Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List 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 CPT codes 15002 and 15003. Our reviewers says that the medical records support the billing of CPT codes 15002 and 15003 provided on October 8, 2020. Our physician reviewer found the enrollee is with diabetes who had necrotizing fasciitis, osteomyelitis, and pressure ulcer.

In this case the operative documents a wound of 9 cm X 13 cm, an area greater than 100 cm2. The operative note reports the excision of necrotic skin, muscle, tissue, and bone. A skin substitute graft was applied. The elements of the requested CPT codes are satisfied. The requested CPT codes are recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT codes 15002 and 15003 have been met. Therefore, we decided that the Plan has to pay for the surgical services described by current procedural terminology (CPT) codes 15002 and 15003 provided on October 8, 2020.

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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the physician services provided from September 24, 2020 to October 6, 2020.

You asked the Plan to pay for the physician services. You say that you would like the Plan the reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is enrolled in the Medicare program. Therefore, we decided that the Plan has to pay for the physician services provided from September 24, 2020 to October 6, 2020.

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 pay for a comprehensive oral evaluation (D0150), bitewing x-rays (D0274), cleaning (D1110), amalgam (D2150) and resin-based composites (fillings) (D2330, D2392) provided on October 29, 2020 and November 10, 2020 by an out-of-network provider.

You asked the Plan to pay for the dental services. You say that you believed these services would be covered. The Plan denied your request. The Plan says they do not cover out-of-network dental care.

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, items or services provided out-of-network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), bitewing x-rays (D0274), cleaning (D1110), amalgam (D2150) and resin-based composites (fillings) (D2330, D2392) provided on October 29, 2020 and November 10, 2020 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), cone beam image capture (D0367), removal of the torus mandibularis (D7473) and intravenous sedation/analgesia (D9239, D9243) provided on September 8, 2020 and September 30, 2020.

You asked the Plan to pay for the dental services. You say that these were medically necessary services and should not be considered dental. The Plan denied your request. The Plan says these services are dental in nature. Therefore, they are not covered by Medicare, and the Plan does not offer additional dental coverage.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Dental services that are medical in nature and are eligible for Medicare coverage include surgery to repair a fractured jaw, extractions to prepare for radiation, some temporomandibular joint treatments, and dentures as part of an obturator prosthesis. The services provided are not considered medical in nature and are not eligible for Medicare coverage. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), cone beam image capture (D0367), removal of the torus mandibularis (D7473) and intravenous sedation/analgesia (D9239, D9243) provided on September 8, 2020 and September 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea.

You asked the Plan to pre-approve Eylea. The Plan denied your request. The Plan says there is little to no documentation of clinical complexities that require Eylea for the requested diagnosis.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

We looked at the file, and Medicare rules. In this case, there are insufficient medical records to show that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve Eylea.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on September 22, 2020.

You asked the Plan to pay for diagnostic radiology services. The Plan denied your request. The Plan says care you receive from an out-of-network provider will not be covered except in the following situations: emergency or urgently needed care that your get from an out-of-network provider, if our plan authorizes the use of an out-of-network provider, if our plan authorizes the use of an out-of-network provider who accepts Medicare assignment, the provider has agreed to accept your cost-sharing and the amount paid by the Plan as payment in full.

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 diagnostic radiology 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 diagnostic radiology services provided on September 22, 2020.
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 LTACH care is medically necessary. The
Plan denied your request. The Plan says rules for LTACH care have not been met.

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 enrollee is a 30-year-old female who was admitted to the hospital due to suffering
cardiac arrest while receiving sedation for a dental procedure. She experienced respiratory failure, requiring
intubation and mechanical ventilatory support, and also experienced seizures and abnormal neurologic activity.
There is no documentation provided necessitating admission to an LTACH. The enrollee is receiving
appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are
not available at the acute care hospital where she is currently receiving care. There are no services available at
the LTACH that the enrollee requires that are not available at the health care setting being offered by the health
plan.

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. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0482) provided on August 25, 2020.

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the record indicates that this specimen was collected in an office setting.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code G0482 is not supported in the record. Specifically, this claim was billed with a laboratory place of service code but the documentation indicates that the member's face-to-face service was rendered in an office setting. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0482) provided on August 25, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services provided by a participating provider on September 10, 2020, to September 11, 2020.

You asked the Plan to waive the copayment for emergency room services. You say that you were admitted, and this should be waived. 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 an $85 copayment for emergency care.

You have been asked to pay an $85 copayment for emergency room services. Unless the provider has written an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost sharing amounts for outpatient hospital services. Emergency room services fall within the emergency care 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 emergency room services provided by a participating provider on September 10, 2020, to September 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating provider on January 30, 2020.

You asked the Plan to waive the copayment for a CT scan. You say that you have never had a copayment left over from your secondary policy. 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 $300 copayment for outpatient diagnostic tests/CT.

You have been asked to pay $107.58 which is less than your copayment amount of $300 for a CT scan. The correct copayment has been applied to the services that were provided. A CT scan falls within the outpatient diagnostic tests/CT 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 a CT scan provided by a participating provider on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 19, 2020.

You asked the Plan to waive the copayment for the office visit. You say that you had no other options at this time. You say that you want the charges allowed. The Plan denied your request. The Plan says the copayment 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 $30 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office.

You have been asked to pay a $30 copayment for the office visit. The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The records show the office visit was with a specialist. 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 office visit provided on November 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device.

You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level (22867). You say that the enrollee needs this device for pain relief. The Plan denied your request. The Plan says the requested device is experimental and more research is needed to show safety and efficacy.

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 pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level (22867). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested device remains experimental, and more research is needed to show safety and efficacy of the device. Also, there is no spinal instability documented therefore hardware is not needed. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level (22867) have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel SureClick (J1438).

You asked the Plan to pre-approve Enbrel SureClick. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Enbrel SureClick (J1438).

Benefits for Enbrel SureClick may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management provided on January 25, 2020.

You asked the Plan to pay for the hospital discharge day management. You say that the enrollee was ill and required continued care until he was stable. The Plan denied your request. The Plan says this date of service will need to be submitted to Original Medicare for consideration of payment because the enrollee became effective under hospice care.

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 hospital discharge day management provided on January 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services described by current procedural terminology (CPT) codes 25332 and 25116 provided on July 7, 2020.

You asked the Plan to pay for CPT codes 25332 and 25116. You say that the medical records support the billing of CPT codes 25332 and 25116 provided on July 7, 2020. The Plan denied your request. The Plan says the medical records do not support the billing of CPT codes 25332 and 25116 provided on July 7, 2020.

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 25332 is Arthroplasty, wrist, with or without interposition, with or without external or internal fixation. The CPT Code Manual definition of code 25116 is Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); extensors, with or without transposition of dorsal retinaculum. 

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 CPT codes 25332 and 25116. Our reviewer says that the medical records do not support the billing of CPT codes 25332 and 25116 provided on July 7, 2020. Our physician reviewer found both codes 25332 and 25116 are not clearly supported by documentation in the operative note for wrist surgery. Not enough detail is present to justify the use of those codes. All operative services needed for each code are not described. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT codes 25332 and 25116 have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services described by current procedural terminology (CPT) codes 25332 and 25116 provided on July 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional sixty miles for routine transportation.

You asked the Plan to pre-approve the additional miles. You say that you need to have a kidney transplant and
you don't have any transportation. The Plan denied your request. The Plan says the plan covers trips up to 50
miles one-way.

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 routine transportation up to 50 miles one-way per trip.

We looked at your request, the records in the case file, and the rules. You are requesting a trip that is over 50
miles one-way. Based on this information, we decided that the Plan's rules for coverage of routine
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve an
additional sixty miles for routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary (D5110) and complete mandibular (D5120) dentures.

You asked the Plan to pay for the maxillary and mandibular dentures. You say that it was the provider's responsibility to obtain prior authorization from the plan before services were rendered. The Plan denied your request. The Plan says you are allowed new dentures once every five plan years, and you last received dentures.

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 are not in excess of those covered under this benefit. The Plan has provided evidence that you received complete upper and lower dentures within the last five years. Therefore, we decided that the Plan does not have to pay for the complete maxillary (D5110) and complete mandibular (D5120) dentures.