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

We decided that the Plan has to provide additional payment for the resin-based composite - one surface, posterior (D2391) provided January 15, 2021.

You asked the Plan to provide additional payment for the posterior white filling - one surface. You say that there should be additional coverage for this service since you have not hit your $1,000 dental maximum. The Plan denied your request. The Plan says that the claim was processed correctly using an alternate code for a silver filling and you are responsible for the difference in price.

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 posterior resin-based composite - one surface with a 20% coinsurance. 

We looked at the file and Medicare rules. The evidence of coverage states that multi-surface white fillings on back teeth will be processed as silver fillings. In this case you had a white filling on one surface. Based on the Plan contract, you cannot be asked to pay for a silver filling. Based on this information, we decided that the Plan's rules for coverage of the posterior resin-based composite - one surface have been met. Therefore, we decided that the Plan has to provide additional payment for the resin-based composite - one surface, posterior (D2391) provided January 15, 2021 and reduce the cost-sharing to 20% of the cost for a white filling.

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: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of nerves innervating the sacroiliac joint (64625).
You asked the Plan to pre-approve radiofrequency ablation of nerves innervating the sacroiliac joint. You say that this request is medically necessary. The Plan denied your request. The Plan says there is no literature to support that this procedure can be considered as being safe, effective or the standard of the care.
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 radiofrequency ablation of nerves innervating the sacroiliac joint. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is considered experimental/ investigational because of the wide variation in efficacy reported in the literature. Therefore, the request 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 radiofrequency ablation of nerves innervating the sacroiliac joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of nerves innervating the sacroiliac joint (64625).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on January 5, 2021.
You asked the Plan to waive the copayment for the colonoscopy. You say that you had biopsy performed during your colonoscopy and should not have a copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $175 copayment for ambulatory surgical center visits.
You have been asked to pay a $175 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical center" benefit category. The medical record shows a diagnosis of ulcerative colitis which makes the colonoscopy diagnostic in nature.
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 colonoscopy provided on January 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient hospital admission for a right shoulder joint replacement surgery (23472).

You asked the Plan to pre-approve an acute inpatient hospital admission. You say that an inpatient hospital admission is medically necessary for the enrollee. The Plan denied your request. The Plan says an inpatient hospital admission for this procedure is not medically necessary.

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 pre-approve an acute inpatient hospital admission. 
Our reviewer says that an acute inpatient hospital admission is not medically necessary. Our physician reviewer found that the enrollee has requested an inpatient hospital admission for an elective right total reverse shoulder arthroplasty procedure. The provided documentation does not suggest that the patient would have a higher than average risk of complication or an expected prolonged recovery in the hospital following this procedure. The records do not support that the patient would require hospital services that would likely cross 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 an acute inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient hospital admission for a right shoulder joint replacement surgery (23472).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 14, 2020 by an out of
network provider.

You asked the Plan to pay for the office visit. You say that you were not notified until recently that the provider
is not contracted. The Plan denied your request. The Plan says you did not request 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 office visit provided on December 14, 2020 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on September 16, 2020.
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 the date the specimen was collected should be the date of service on the claim.
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 G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type,
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed." We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the laboratory testing documents specimen collection was performed on September 14, 2020 and reported date of service September 16, 2020 with place of service 11. Per CMS Medicare-Clinical Laboratory Fee Schedule- Laboratory Date of Service Policy "In general, the date of service (DPS) for clinical diagnostic laboratory tests is the date of specimen collection unless the physician orders the test at least 14 days following the patient's discharge from the hospital. When the "14-day rule" applies, the DOS is the date the test is performed, instead of the date of specimen collection." Therefore, this claim was billed incorrectly. We looked at this coder's review, the file, and Medicare rules. 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 drug testing services (HCPCS G0483) provided to the enrollee on September 16, 2020.
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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a reaching/grabbing device (A9281), orthopedic footwear (L3215) and sales tax (S9999).

You asked the Plan to pay for the grab bar or orthopedic footwear. You say that the items should be covered, and that your husband's claim was covered partially. The Plan denied your request. The Plan says the services are not coverable benefits.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Additionally the orthopedic shoes at the billed code are not covered per the Local Coverage Article. Therefore, we decided that the Plan does not have to pay for a reaching/grabbing device (A9281), orthopedic footwear (L3215) and sales tax (S9999).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Free Style Libre 14 Day Reader (K0554) and Sensor (K0553).

You asked the Plan to pre-approve the Free Style Libre 14 Day Reader and Sensor. The Plan denied your request. The Plan says the enrollee is testing their blood sugar twice daily. The Plan also says that the enrollee is currently treated with Lantus once daily.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day and use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the Free Style Libre 14 Day Reader and Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Free Style Libre 14 Day Reader (K0554) and Sensor (K0553).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on December 9, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that the member was ensured that this procedure would be covered in full. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $365 copayment for outpatient surgery/in-network/outpatient hospital.
The enrollee has been asked to pay a $365 copayment for an outpatient surgery. The correct copayment has been applied. An outpatient surgery falls within the outpatient surgery/in-network/outpatient hospital benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on December 9, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay foradjacent tissue transfer or rearrangement (14001) provided on September 29, 2020.You asked the Plan to pay foradjacent tissue transfer or rearrangement. You say that this is supported.The Plan denied your request. The Plan says that this was not billed with an appropriate code.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 14001 is adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm.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 adjacent tissue transfer or rearrangement. Our reviewers says that the records support the billed code. Our physician reviewer found the operative report documents additional incisions along with extensive undermining.  Per CPT guidelines for adjacent tissue transfer, "Undermining alone of adjacent tissue to achieve closure, without additional incision does not constituteadjacent tissue transfer, see complex repair codes 13100 -13160."  If an additional incision is not performed, you would report a complex repair code. Therefore, CPT 14001 is confirmed as performed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of adjacent tissue transfer or rearrangement have been met.Therefore, we decided that the Plan has to pay foradjacent tissue transfer or rearrangement (14001) provided on September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office services (CPT Code(s): 99204 and 99214), and percutaneous tests (scratch, puncture, prick) with allergenic extracts (CPT Code 95004) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says the medical record received did not show that you have an emergent or urgent medical condition or are in need of specialized service. The Plan states there are multiple in-network specialty provider(s) within a reasonable distance from your location that can provide this service/item.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office services (CPT Code(s): 99204 and 99214), and percutaneous tests (scratch, puncture, prick) with allergenic extracts (CPT Code 95004) to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Group 2 standard power wheelchair provided on January 21, 2021.
You asked the Plan to waive the coinsurance for the Group 2 standard power wheelchair. You say that you were told by the supplier that you would not have to pay anything. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Durable Medical Equipment. You have been asked to pay 20% coinsurance for the Group 2 standard power wheelchair. The Group 2 standard power wheelchair falls within the Durable Medical Equipment 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 the Group 2 standard power wheelchair provided on January 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the surgery is medically necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 the surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation trips.

You asked the Plan to pre-approve the additional trips. You say that you would like more transportation trips to be approved. You say that you have used your 20 one-way trips. You also say that you have appointments on April 9, 2020, and April 15, 2020. The Plan denied your request. The Plan says 20 one-way trips to plan-approved locations every year are covered. The Plan also says that the frequency limit has been reached.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional transportation trips.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 19, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 19, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 19, 2020.