Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on August 3, 2020. You asked the Plan to pay for the orthosis. You say that this product was reasonable in reference to treatment of the patient's condition. The Plan denied your request. The Plan says that your request is not medically necessary because your records do not support the need or justification for the brace. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on August 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for aphasia and was diagnosed with conversion disorder. The medial records state the enrollee remains unable. unwilling to talk. The enrollee has been discharged to home where she has balance problems and weakness. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study (CPT 95810).
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your request. The Plan says services that are not medically necessary are not covered under the health benefit plan.
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 study. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have known OSA, and are using CPAP successfully. The clinician is ordering a new PSG for reasons that are not clear in the record. You want a sleep study to qualify for supplemental oxygen, which you have had in the past. There have been no major clinical changes or new symptoms that would justify a new sleep study. 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 study have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study (CPT 95810).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the initial periapical x-ray (D0220), 4 additional periapical x-rays (D0230), the panoramic x-ray (D0330), and the prophylaxis (D1110) provided on September 30, 2020.
You asked the Plan to pay for the dental services. You say that The Plan denied your request. The Plan says there is a $1,000 combined allowance for supplemental preventive and comprehensive services every year. The Plan says that the allowance has been exhausted. The Plan also says that you are responsible for any amount over and above the allowance amount.
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 $1,000 annual allowance has been exhausted.The Evidence of Coverage clearly states that you are responsible for any amount over and above the allowance amount. The record shows that prior to this date of service, you had used a total of $838 of the $1,000 maximum. The total amount charged for the claim for this date of service was $287. The Plan paid $162 in which the $1,000 allowance was reached. The remaining amount of $125 is your responsibility. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the initial periapical x-ray (D0220), 4 additional periapical x-rays (D0230), the panoramic x-ray (D0330), and the prophylaxis (D1110) provided on September 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services coded 99239 provided on September 27, 2019.
You asked the Plan to pay for the subsequent hospital care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not payable.
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 99233 is hospital discharge day management; more than 30 minutes. We find that CPT code 99233 is not supported in the medical record. Specifically, another hospital care service was billed, processed, and paid by the plan. This service is inclusive to the service already paid. Therefore, it is not separately payable. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services coded 99239 provided on September 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive service (D1999) provided from September 17, 2020.
You asked the Plan to pay for the unspecified preventive service. You say that you were referred by your regular dentist. You say that because you were referred by an in network dentist, you should be reimbursed for the fees that you have already paid. The Plan denied your request. The Plan says the unspecified preventive service 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 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 unspecified preventive service (D1999) provided from September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for nerve block and injection procedure, prone position (01992) provided January 21, 2020.
You asked the Plan to pay for the monitored anesthesia. You say that please reprocess these claims allowing benefits for services provided. The Plan denied your request. The Plan says the medical record does not establish the need for this sedation. CPT code 01992 and 62323 cannot be billed together, and no modifier is allowed.
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 01992 is anesthesia for nerve block and injection procedure, prone position 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 the monitored anesthesia. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee had a lumbar epidural steroid injection under sedation. The enrollee was listed as ASA Physical Status 2. No unstable medical condition is noted in the pre-anesthetic evaluation or airway issue. There was no indication for moderate sedation during this procedure. The procedure was 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 monitored anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for nerve block and injection procedure, prone position (01992) provided January 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedeep sedation for dental services (D9222, D9223).You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis 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.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 Plandoes not haveto pre-approvedeep sedation for dental services (D9222, D9223)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetransparent sterile film (more than 16 sq in, but less than or equal to 48 sq in).You asked the Plan to pre-approvethe services. You say that you need this to be able to shower instead of taking sink baths.The Plan denied your request. The Plan says you do not have a qualifying wound as required.The Plan must follow Medicare rules. The rules say that there must be a qualifying wound for surgical dressings to be covered.A dialysis access port on your chest would not qualifyas a qualifying wound. 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 pre-approvetransparent sterile film (more than 16 sq in, but less than or equal to 48 sq in).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the life vest provided on August 4, 2020.

You asked the Plan to waive the cost share for the provided services. You say that you refused to wear the device because the sensors kept going off. The Plan denied your request. The Plan says the claim processed correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for durable medical equipment. 

You have been asked to pay a 20% coinsurance for the provided device. The device 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 cost share for the life vest provided on August 4, 2020. 

Your complaint about the quality of the life vest 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish provided on September 18, 2020.
You asked the Plan to pay for the topical application of fluoride varnish. You say that you were not advised that this service was no longer covered. The Plan denied your request. The Plan says this service is not covered.
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 topical application of fluoride varnish provided on September 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for other procedures of the hemic or lymphatic system (38900) biopsy or excision of lymph node (38525) mastectomy, partial (19301) provided July 9, 2020.
You asked the Plan to pay for the surgical procedure. You say that both the primary surgeon and facility are in-network and that CPT 38900 is payable to the assistant surgeon so you request the assistant surgeon's claim be processed at the in network. The Plan denied your request. The Plan says the prescribing/ordering provider is not eligible to prescribe/order the service billed.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for other procedures of the hemic or lymphatic system (38900) biopsy or excision of lymph node (38525) mastectomy, partial (19301) provided July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe unspecified preventive service (D1999), core build up (D2950 x 4), crowns (D2740 x 2), and the inhalation of nitrous oxide (D9230) provided from August 10, 2020, to September 14, 2020.You asked the Plan to pay forthe dental services. You say that you paid the required amounts for crowns on 2 occasions which included core build up. You say that the separate charge for core build up is unnecessary as it is essential for the crown procedure. You say that you feel you do not owe anymore fees for these services. You also say that the balance is the responsibility of the plan.The Plan denied your request. The Plan says additional payment cannot be made for the unspecified preventive service as the provider receives a separate monthly stipend for this service. The Plan says you pay 70% for up to 2 crowns per calendar year. The Plan says that the frequency limit has been exceeded. The Plan says that core build up is not listed as a covered service. The Plan also says that the nitrous oxide is only covered when the services it is provided in conjunction with are also covered.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, core build up and the unspecified preventive service are not among those covered under this benefit. The frequency limit of 2 crowns per calendar year has been exceeded. The record shows the Plan paid the in network cost share for 2 crowns that you received on August 10, 2020. Additionally, nitrous oxide is only covered hen it is provided with other covered services.Therefore, we decided that the Plan does not have to pay forthe unspecified preventive service (D1999), core build up (D2950 x 4), crowns (D2740 x 2), and the inhalation of nitrous oxide (D9230) provided from August 10, 2020, to September 14, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant-at-surgery services provided on June 16, 2020.
You asked the Plan to pay for the assistant-at-surgery services. You say that the Plan should pay this claim. The
Plan denied your request. The Plan says the services were performed by a Registered Nurse First Assistant not
recognized for payment by CMS.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the
procedure is covered for an assistant and the person who assists the surgery bears the designation of a
physician, PA, NP, or CNS.
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP,
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant-at-surgery services
provided on June 16, 2020.
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 you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.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 medically necessary. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He has a history of traumatic brain injury with paraplegia bilateral lower extremities and hemiplegia right upper extremity.  His medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital care provided by a participating provider on November 27, 2019, to December 1, 2019.
You asked the Plan to waive the copayment for an inpatient hospital care. You say that you shouldn't have to pay for this because so much time has lapsed. 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 $375 copayment per day for days 1-4. There is a $0 copayment for additional days for inpatient hospital care/in-network. You have been asked to pay $750 for an inpatient hospital care. An inpatient hospital care falls within the inpatient hospital care/in-network 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 inpatient hospital care provided by a participating provider on November 27, 2019, to December 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a mask, fleet glycerin and cough relief provided on September 23, 2020 and September 29, 2020
You asked the Plan to pay for a mask, fleet glycerin and cough relief. You say that the items should be covered. The Plan denied your request. The Plan says you have exhausted your Plan's maximum benefit for this service.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the supplemental benefits for over-the-counter items have not been met. Specifically, records show that you exceeded your maximum benefit for the third quarter. This means the services are not covered. Therefore, we decided that the Plan does not have to pay for a mask, fleet glycerin and cough relief provided on September 23, 2020 and September 29, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options. You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary. The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC is covered when specific criteria are met. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee had a stroke with left hemiplegia and hemiparesis. She has a mobility limitation due to a neurological condition of a stroke. She does not meet the coverage criteria for the power tilt and recline system. She is not at high risk for development of a pressure ulcer. She does not use intermittent catheterization or a ventilator. The power seating system is not needed to manage increased tone or spasticity. The enrollee's strength and function are sufficient to control any power options through their own switches. The criteria for coverage of the Group 3 PWC are not met and the services are 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options.