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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the prophylaxis (D1110) provided on September 16, 2019 by the out of network provider.
You asked the Plan to pay for the dental services. You say that the dentist in this case is your original dentist. You say that he went into semi-retirement and his practice merged with another. You say that you were not informed that the new office was out of network until after you received the services. The Plan denied your request. The Plan says dental services received out of network are not covered. The Plan also says that the provider in this case in not a network 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. Though the Plan offers a dental benefit in excess of Medicare coverage and oral exams and cleanings are covered services, the dental services are not covered when you receive them out of network. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the prophylaxis (D1110) provided on September 16, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on October 14, 2019.
You asked the Plan to pay for the prophylaxis. You say that your treatment was scheduled for you by your doctor who recommended 3 visits per year rather than two. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, cleanings are limited to two procedures per plan year. The record shows that you received prophylaxes on January 2, 2019 and June 13, 2019 and your cleanings benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on October 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150), the prophylaxis (D1110), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on October 29, 2019.You asked the Plan to pay forthe dental services. You say that you were advised by a plan representative that you would have no fees at all. You say that you are unable to pick up your dentures because you do not have money to pay your balance of $190. You also say that you are on food stamps and barely have money to survive.The Plan denied your request. The Plan says the oral exam, prophylaxis and periapical x-rays are not listed as covered services.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services that you received are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150), the prophylaxis (D1110), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on October 29, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebilateral facet joint injections.You asked the Plan to pre-approvethe bilateral facet joint injections. You say that you have been suffering from back, leg, and knee pain since last fall. You say that you have had numerous tests, which have revealed severe back disc degeneration and nerve pain in your back and leg/knee. You say that you have had 2 epidural injections 10 to 12 years ago, which helped. You say that you are allergic to all muscle relaxers and pain medications.The Plandenied your request. The Plan says the enrollee does not meet the criteria for coverage.The Plan follows Medicare rules. Medicare rules say that fact joint injection are covered for certain medical indications. 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 bilateral facet joint injections. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has radicular pain and probable multiple pain generators. The LCD criteria requires that facet joint pathology be the diagnosis of exclusion. The enrollee has multiple pain generators. Therefore, the requested procedure is considered not medically reasonable or 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 bilateral facet joint injections have not been met.Therefore, we decided that the Plan does not have to pre-approvebilateral facet joint injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF 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 above.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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF.  In this case, the enrollee is requiring assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable and predicted period.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99204), and an electrocardiogram (ECG) (93000) provided on August 26, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit and an ECG. You say that you are requesting the supporting documentation be reviewed as the services were deemed payable.The Plan denied your request. The Plan says if you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. Authorization must be obtained from the plan's Medical Director prior to seeking care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The 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 theitem/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 foran office visit (99204), and an electrocardiogram (ECG) (93000) provided on August 26, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray and consultation provided on December 20, 2019.
You asked the Plan to pay for the panoramic x-ray and consultation. You say that these services were a medical necessity. The Plan denied your request. The Plan says these services are not covered under your plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray and consultation provided on December 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient detoxification admission.You asked the Plan to pre-approvean inpatient detoxification admission. You say that the medical records provided support the need for the inpatient admission.The Plan denied your request. The Plan says the records received show that the enrollee's condition has improved and that he no longer meets inpatient detoxification criteria for coverage.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 an inpatient detoxification admission. Our reviewer says that the requested inpatient detoxification admission is not considered medically reasonable and necessary in this case. Our physician reviewer found as of February 26, 2020 the enrollee appeared neat and clean and was cooperative and denied depression or anxiety. His mood was described as anxious and depressed. He was not currently showing any alcohol withdrawal symptoms. He did not have alcohol cravings. He was not having symptoms of acute or dangerous alcohol withdrawal that required 24-hour medical detoxification. He was no longer on an alcohol withdrawal or detoxification protocol and his sleep and appetite were adequate. His vital signs were stable and he was not having delirium. The enrollee was medically stable and tolerating his medical regimen.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient detoxification admission have not been met.Therefore, we decided that the Plan does not have to pre-approvean inpatient detoxification admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the reline maxillary partial denture (D5740) provided on November 25, 2019.
You asked the Plan to pay for the dental service. You say that even though the service is not covered, the enrollee needs the partial denture to be fixed. You say that the enrollee has no top front teeth and cannot eat. You also say that the enrollee almost choked a few times because he cannot properly chew. The Plan denied your request. The Plan says the reline of the maxillary partial dentures is not listed as a covered service.
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 reline of the maxillary partial denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the reline maxillary partial denture (D5740) provided on November 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on July 1, 2019 billed
under codes 22854 and 63090.
You asked the Plan to pay for codes 22854 and 63090. You say that this claim should be paid. The Plan denied
your request. The Plan says the records provided do not support the services billed. Procedure code 22854-80-
59 is not supported by the medical records submitted. The Plan states the operative report did not include
documentation of an insertion of intervertebral biomechanical device(s) (synthetic cage, mesh), with integral
anterior instrumentation for device anchoring (screws, flanges) when performed, to vertebral corpectomy(ies)
(vertebral body resection, partial or complete) defect, in conjunction with inter body arthrodesis, for each
contiguous defect (listed separately in addition to code for primary procedure); therefore this code cannot be
verified. The Plan further states that for procedure code 63090-80-59 the operative report did not include
documentation of a partial or complete vertebral corpectomy (vertebral body resection),using a transperitoneal
or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic,
lumbar, or sacral; for a single segment (Listed separately in addition to code for primary procedure); therefore
this code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code and when necessary provide the medical records
to support the services billed. In this case the records provided are limited and do not support the claim billed.
Medicare rules for coverage of codes 22854 and 63090 have not been met. Therefore, we decided that the Plan
does not have to pay for lab services provided to the enrollee on July 1, 2019 billed under codes 22854 and
63090.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ambulance trip provided on September 28, 2019.You asked the Plan to waive the copayment foran ambulance trip. You say that you have never been charged in the past and disagree with the 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 a $325 copayment for ambulance services. You have been asked to pay a $325 copayment for an ambulance trip. An ambulance trip falls within the ambulance 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 copayment foran ambulance trip provided on September 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebone marrowaspiration (20939).You asked the Plan to pre-approvebone marrow aspiration (20939). You say that the requested bone marrow aspiration is medically necessary.The Plan denied your request. The Plan says the requested bone marrow aspiration is 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 pre-approve bone marrow aspiration (20939). Our reviewer says that the requested bone marrow aspiration is not medically necessary. Our physician reviewer found the enrollee is with neck pain radiating down both arms. The enrollee scores the pain as 8/10 and has documented failure of conservative treatments. The Plan approved the requested anterior cervical discectomy and fusion. However, bone marrow aspiration remains experimental. Moreresearch is needed. The requested bone marrow aspiration is not medically necessary 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 bone marrow aspiration (20939) have not been met.Therefore, we decided that the Plan does not have to pre-approvebone marrow aspiration (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation of a new patient (99204) provided on June 4, 2019.
You asked the Plan to pay for the new patient evaluation. You say that the member has not been seen by providers with the same taxonomy. The Plan denied your request. The Plan says the records show this provider billed for Date of Service June 04, 2019 procedure code 99204 Office or other outpatient visit for the evaluation and management of a new patient, under the same provider, Tax Identification number, Taxonomy number and the National Provider Identifier number.
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 99204 is office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.
We find that CPT code 99204 is not supported in the record. Specifically, the record indicates that this provider billed the same new patient evaluation code (99204) for this member on April 22, 2019. Based on this information, we decided that Medicare rules for coverage of the new patient evaluation have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation of a new patient (99204) provided on June 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the gum surgery (D4266) for teeth 4, 5, 12 and 23.You asked the Plan to pre-approve the gum surgery. You say that you are not able to pay for this procedure and the dentist will not pull the teeth without this done. If you cannot get the teeth extracted you are in danger of another hospital stay.The Plan denied your request. The Plan says this service is not listed as 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. The health plan contract specifically says that any service not listed is not covered.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve the gum surgery (D4266) for teeth 4, 5, 12 and 23
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tadalafil 20mg tablets.
You asked the Plan to pre-approve Tadalafil. You say that the drug is medically necessary. The Plan denied your request. The Plan says coverage for Tadalafil is not available under the Part B medical benefit.
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 Tadalafil 20mg tablets.
Benefits for Tadalafil 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on October 26, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on October 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Ultimate Travel Scooter, or power operated vehicle (POV).
You asked the Plan to pre-approve the scooter. The Plan denied your request. The Plan says the documentation is insufficient to support the medical necessity of the POV.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that there is insufficient evidence to show that you have a mobility deficit that impairs your participation in MRADLs, your condition cannot be improved by a walker, cane or manual wheelchair, or that you can safely operate the POV being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve an Ultimate Travel Scooter, or power operated vehicle (POV).