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

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on February 4, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, and an intraoral complete series of radiographic images. You say that you were not aware of the frequency limitation. The Plan denied your request. The Plan says the comprehensive oral evaluation is a covered benefit, but you have exceeded the frequency limit of one every 3 years. The Plan also says that an intraoral complete series of radiographic images is 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.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, and an intraoral complete series of radiographic images have not been met. Specifically, the record shows that you had exceeded the frequency limit for the comprehensive oral evaluation prior to this service on July 11, 2019. Additionally, an intraoral complete series of radiographic images is not a covered benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on February 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on December 8, 2020.
You asked the Plan to pay for foot orthotics. You say that this was medical equipment needed following my surgery. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for application of skin substitute graft (15275) provided on February 16, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the wound care services. You say that please approve the authorization and reprocess the claim. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 application of skin substitute graft (15275) provided on February 16, 2021 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an incision and drainage of abscess (10061) reported as provided on July 27, 2020.
You asked the Plan to pay for an incision and drainage of abscess. You say that the coding at issue is supported by medical records. The Plan denied your request. The Plan says records do not support the service 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. In this case, the CPT Code Manual definition of code 10061 is "Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple." We asked our coder 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 an incision and drainage of abscess. Our reviewer says that the billed code does not meet criteria for billing or reimbursement consideration. Our coder reviewer found that the medical records provided do not include sufficient documentation to validate an incision and drainage of abscess; complicated or multiple; therefore this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an incision and drainage of abscess have not been met. Therefore, we decided that the Plan does not have to pay for an incision and drainage of abscess (10061) reported as provided on July 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular-respiratory risk assessment testing / panels provided to the enrollee on June 25, 2020.
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Review of the file show that the enrollee received cardiovascular-respiratory risk assessment testing / panels on June 25, 2021. Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. Therefore, we decided that the
Plan does not have to pay for cardiovascular-respiratory risk assessment testing / panels provided to the enrollee on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance payment for two (2) ferric carboxymaltose
injections (J1439) provided on February 19, 2021, to February 26, 2021.

You asked the Plan to waive the coinsurance payment for injections. You say that you had these injections in
2019 and never paid a cost share. The Plan denied your request. The Plan says the coinsurance you are being
charged is correct.

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 20%
coinsurance for Medicare Part B prescription drugs.

You have been asked to pay a 20% coinsurance for each injection visit. The EOC confirms 20% is the required
coinsurance for this service. The allowed amount of the claim is $847.50, resulting in a coinsurance obligation
of $169.50 per visit. You had two visits for a total cost-share of $339 (169.50 x 2 visits = $339). The records
show that for the year 2019, you did not have a copayment for injections. Injections fall within the Medicare
Part B prescription drugs 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 coinsurance payment for
two (2) ferric carboxymaltose injections (J1439) provided on February 19, 2021, to February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the eye refraction (CPT code 92015) provided on February 16, 2020.
You asked the Plan to pay for the eye refraction. You say that your doctor wants to follow up before the two-year mark of you being eligible to receive another eye exam, due to your poor vision caused by your diabetes. The Plan denied your request. The Plan says that your supplemental vision benefits allows you to receive one (1) refraction service every two (2) years.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. the Plan did not forward over a copy of the evidence of coverage (EOC) that specifies your supplemental vision benefits. Therefore, we decided that the Plan has to pay for the eye refraction (CPT code 92015) provided on February 16, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a consultation (D9310), pulp vitality tests (D0460), intraoral periapical radiographic images (D0220, D0230), and a bitewing radiographic image (D0270) provided on November 18, 2020.

You asked the Plan to pay for a consultation, pulp vitality tests, intraoral periapical radiographic images, and a bitewing radiographic image. You say that you were not aware that the provider was out of network. The Plan denied your request. The Plan says dental services are not covered when rendered by a non-participating provider.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a consultation, pulp vitality tests, intraoral periapical radiographic images, and a bitewing radiographic image have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. Therefore, we decided that the Plan does not have to pay for a consultation (D9310), pulp vitality tests (D0460), intraoral periapical radiographic images (D0220, D0230), and a bitewing radiographic image (D0270) provided on November 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does require skilled nursing or therapy services on a daily basis. This beneficiary does meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam image capture (D0367) provided on January 18, 2021.
You asked the Plan to pay for the dental imaging. You say that your provider told you this service was necessary. The Plan denied your request. The Plan says this service is not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam image capture (D0367) provided on January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on December 4, 2020.
You asked the Plan to pay for the prophylaxis. You say that the Plan coverage indicates that this procedure is covered. You also say that the documentation does not make any reference to frequency limitations. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
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, prophylaxis (D1110) is limited to two procedures per plan year. The record shows that you received a prophylaxis (D1110) on March 9, 2020, and July 14, 2020, and your prophylaxis (D1110) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on December 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 18, 2021.
You asked the Plan to pay for a limited oral evaluation. You say that the service was necessary due to an emergency. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every year.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on March 4, 2021. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on February 23, 2021 by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that a Plan representative recommended you be seen by this provider. You also say that you were told this provider accepted your insurance. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you were provided the names and information for two in-network dentists, and were mailed a list on in-network providers.
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, you are responsible for 100% of the cost for dental services received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on February 23, 2021 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the chest (71250) provided January 20, 2021.
You asked the Plan to waive the copayment for the CT scan of the chest. You say that you were told you would only have one copayment. The Plan denied your request. The Plan says the copayment has processed correctly in this case.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for Medicare-covered CT scan. You have been asked to pay a $15 copayment for the CT scan of the chest. This service falls within the Medicare-covered CT scan 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 computed tomography (CT) scan of the chest (71250) provided January 20, 2021.
Your complaint about potentially receiving misinformation regarding your copayment is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Keytruda. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the enrollee with metastatic non-small cell carcinoma of the lung was started on carboplatin and pemetrexed and has received 3 cycles. There is no documentation of progression for programmed death-ligand 1 (PD-L1). Pembrolizumab (Keytruda) would not be indicated at this time. The service is not reasonable or 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the abdomen (74175).

You asked the Plan to pre-approve a CTA of the abdomen. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CTA of the abdomen. Our reviewer says that the services are not medically necessary. Our physician reviewer found the note does not support the medical necessity or reasonableness of the requested service. The elements of the coverage rule are not satisfied. The requested service cannot be recommended at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CTA of the abdomen have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of the abdomen (74175).