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

We decided that the Plan does not have to pre-approve retainer crowns (D6751) for teeth # 6, 8, and 11, and
pontics (D6241) for teeth # 7, 9 and 10.
You asked the Plan to pre-approve the dental services. You say that you are in a lot of pain. You say that the
pain interferes with eating and cannot enjoy hard food. You say that you are losing weight. You also say that
you no longer smile. The Plan denied your request. The Plan says bridges are not covered when there are
posterior teeth missing.
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 and bridges are a covered service, they
are not covered when there are posterior teeth missing. The record shows that you have a posterior tooth, # 14,
missing. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6751) for teeth #
6, 8, and 11, and pontics (D6241) for teeth # 7, 9 and 10.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services provided to the enrollee from October 30, 2019 to November 6, 2019 and billed under code S9328.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare billing criteria were not met.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the code billed has a status code indicator of "I" which that does not allow payment on Medicare claims. Therefore, we decided that the Plan does not have to pay forhome infusion services provided to the enrollee from October 30, 2019 to November 6, 2019 and billed under code S9328.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on August 8, 2019.
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 procedure code 95999 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular
diagnostic procedure.
We find that CPT code 95999 is not supported in the medical record. Specifically, the file shows that train of
four testing was performed and there is a more appropriate code for these services. Based on this information,
we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that
the Plan does not have to pay for the services rendered to the enrollee on August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion supplies provided on May 15, 2019 and June 10, 2019. You asked the Plan to pay for the infusion supplies (A4222). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the supplies are inclusive under services approved and paid in Outpatient Prospective Payment System to the facility.
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 A4222 is infusion supplies for external drug infusion pump. Medicare's payment for the supplies billed to the MAC includes payment for the equipment and they are not separately payable. Based on this information, we decided that Medicare rules for coverage of the infusion supplies (A4222) have not been met. Therefore, we decided that the Plan does not have to pay for the infusion supplies provided on May 15, 2019 and June 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns for tooth #'s 6 & 7.You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says because the submitted x-rays are non-diagnostic, they cannot make a medical necessity determination regarding the procedure.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 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. Our reviewer says that the service is not medically necessary. Our physician reviewer found the criteria for coverage for a crown includes the presence of significant coronal breakdown due to caries or fracture. Our reviewer also found that in this case, the documentation provided for crowns for tooth#'s 6 and 7 does not meet the criteria for coverage.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 have not been met.Therefore, we decided that the Plan does not have to pre-approve crowns for tooth #'s 6 & 7.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 70450) provided to the enrollee on November 3, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says Medicare does not pay separately for this service.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 70450 is "Computed tomography, head or brain."We find that CPT code 70450 is not supported in the medical record. Specifically, this code is a column II procedure to the column I procedure already billed on this claim -CPT 70496. This code cannot be billed separately. Based on this information, we decided that Medicarerules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forradiology services (CPT 70450) provided to the enrollee on November 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee brace described by code L1843.
You asked the Plan to pre-approve the requested knee brace. You say that you need this brace to help with your condition. The Plan denied your request. The Plan says there is no recent surgery or injury and no documented instability of the knee to support the need for this type of brace.
The Plan follows Medicare rules. Medicare rules say that knee braces described by code L1843 may be covered for enrollees with recent injury/surgery of the knee or those who are ambulatory with documented instability. 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 requested knee brace. Our reviewer says that the requested brace is not considered reasonable and necessary based on LCD criteria. Our physician reviewer found the patient presents with right knee pain reported at 7-8/10. Onset was 5 years ago and pain duration is intermittent. Prior treatment was knee bracing and pharmaceutical treatment. The patient is ambulatory but there is no documentation of objective right knee instability on a physical examination. There is no evidence of a recent surgery or injury to the right knee. For these reasons the request for the L1843 brace 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 the requested knee brace have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee brace described by code L1843.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2025) bifocal lenses (V2200) and anti-reflective (V2750) purchased on September 17, 2019.
You asked the Plan to pay for the vision services. You say that you are surprised that you will not be reimbursed. The fact that the exam is done by an ophthalmologist or an optometrist is of no relevance. The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network optical provider
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by a network optical provider.
We looked at the file and the Plan's rules. services are covered when you receive services provided by a network optical provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for deluxe frames (V2025) bifocal lenses (V2200) and anti-reflective (V2750) purchased on September 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (HCPCS S9328) provided to the enrollee from December 9, 2019 to December 16, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is an invalid procedure code for this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (HCPCS S9328) provided to the enrollee from December 9, 2019 to December 16, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room care provided on December 2, 2019.
You asked the Plan to waive the copayment for emergency room care. You say that you didn't know you would have a copayment. You say that you cannot afford this 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 $110 copayment for emergency care. You have been asked to pay a $110 copayment for emergency room care. Since an emergency care was given, the correct copayment has been applied. Emergency room care falls 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 care provided on December 2, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325).
You asked the Plan to pre-approve Synvisc-One. You say that this is covered under Medicare guidelines. The Plan denied your request. The Plan says the enrollee has not tried Monovisc and Orthovisc as required by step therapy rules.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Synvisc-One. Our reviewer says that the criteria for coverage of Synvisc-One have not been met. Our physician reviewer found the Plan requires a trial of Monovisc and Orthovisc before they will approve the requested drug. The documentation does not support that the enrolee has tried Monovisc and Orthovisc or that these drugs would likely be less effective or have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One (J7325).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea prefabricated post and core in addition to crown and a crown.You asked the Plan to pre-approvethe post and core and crown. You say that your previous crown fell off and you need a new crown to replace it.The Plandenied your request. The Plan says your plan does not cover these procedures.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-approvea prefabricated postand core in addition to crown and a crown.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 22, 2019
to July 23, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the Medicare criteria for coverage
were met. The Plan denied your request. The Plan says the enrollee did not have a severity of illness that
warranted inpatient care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the enrollee's abdominal pain and rectal bleeding both quickly resolved after her
emergency room evaluation. The enrollee maintained normal vital signs and was never febrile. The blood work
became normal after initial treatment with antibiotics which were quickly switched to self -administered oral
medications. The imaging showed only colitis. The record does not show that at the time of inpatient admission
the admitting physician reasonably expected that the patient's necessary hospital care would span two
midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided from July 22, 2019 to July 23, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care (99310), prolonged service in the inpatient setting (99356), and the psychotherapy services (90833) rendered by out of network (OON) provider on October 14, 2019.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says these services were provided by an out of network provider, without prior authorization.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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 forthe subsequent nursing facility care (99310),prolonged service in the inpatient setting (99356), and the psychotherapy services (90833) rendered by the out of network (OON) provideron October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for surgical supplies provided from July 1, 2019 to July 18, 2019.
You asked the Plan to waive the coinsurance for surgical supplies. You say that you disagree with the out-of-network charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 20% coinsurance for medical supplies. You received surgical supplies from July 1, 2019 to July 18, 2019. The total allowed amount is $20.60 and 20% of that is $4.12. You have been asked to pay the total coinsurance amount of $4.12 for surgical supplies. Surgical supplies fall within the outpatient hospital services 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 for surgical supplies provided from July 1, 2019 to July 18, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room Services (99284, A9270) provided October 18, 2019 by provider.The plan does not need to pay for the self-administered drugs provided during the Emergency Room visit.You asked the Plan to waive the copayment for the Emergency Room Services. You say that the injuries resulted from an elevator accident at the hospital and the hospital should be responsible.The Plan denied your request. The Plan says the correct cost-sharing was 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 $75 copayment for Emergency Care, and that self-administered drugs provided in the outpatient setting are not covered under the Medical Benefit.You have been asked to pay a $75 copayment for the Emergency Room Services. The Emergency Room Services falls within the Emergency Care benefit category. You have been asked to pay $4.00 for self-administered medications provided during the visit. The Emergency Room is considered an outpatient setting. 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 (99284, A9270) provided October 18, 2019 by provider.Please note that per the health plan, you should contact the hospital directly about filing a claim for reimbursement for expenses related to the accident.The Self-administered drugs may be eligible for reimbursement under your Part D Prescription Drug plan. Contact your Part D plan for details
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by in-network physicians on August 21, 2019 to September 16, 2019.You asked the Plan to waive the copayment for an x-ray. You say that you feel like your insurance company should pay for this. The Plan denied your request. The Plan says the correct copayments have 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 $14 copayment for outpatient diagnostic tests/in-network/x-ray. You have been asked to pay a $14 copayment for each x-ray. The total amount you are being asked to pay is $28 ($14 x 2 x-rays = $28). The office visit copayment has been waived. An x-ray falls within the outpatient diagnostic tests/in-network/x-ray 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 x-ray provided by in-network physicians on August 21, 2019 to September 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe portable X-ray services (73590, Q0092, R0075) provided on August 25, 2019.You asked the Plan to pay forthe portable X-ray services. You say that the facility is supposed to verify the enrollee's insurance information.The Plan denied your request. The Plan says the enrollee has no out-of-network benefits. The services were not pre-authorized or emergent.Medicare rulessay 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 forthe portable X-ray services (73590, Q0092, R0075) provided on August 25, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the medical services provided to the enrollee by an out-of-network provider on January 18, 2019.