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

We decided that the Plandoes not haveto pre-approvea semi-electric hospital bed for the enrollee.You asked the Planto pre-approvethe hospital bed. You say that this is medically necessary.The Plandenied your request. The Plansaysthis denial is appropriate given the clinical scenario.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.We asked our physician reviewer to carefully review the case file and applythe relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the hospital bed. Our reviewer says that the requested hospital bed is not medically reasonable or necessary. Our physician reviewer found the documentation does not clearly reveal that enrollee's condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for an immediate or frequent changes in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically necessary for this enrollee.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 hospital bed have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea semi-electric hospital bed for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Magnetic resonance (eg, proton) imaging, brain (including brain stem) (70551) and duplex scan of extracranial arteries (93880) provided August 28, 2020.
You asked the Plan to waive the copayment for the diagnostic services. You say that you had a CT scan and MRI and was asked to disburse $110 at the time of service. You are retired and on a fixed income and not happy with the way the plan is processing claims and the high copayments. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.
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 $110 for each radiological diagnostic service, not including x-rays for Outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay $220 ($110 + $110) for the diagnostic services. The diagnostic services fall within the Outpatient diagnostic tests and therapeutic services and supplies 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 Magnetic resonance (eg, proton) imaging, brain (including brain stem) (70551) and duplex scan of extracranial arteries (93880) provided August 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Covidtesting provided on August 13, 2020.You asked the Plan to pay forthe Covid testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes G2024 and U0003 are not supported in the medical record. Specifically, the submitted documentation did not contain any authenticated medical records (e.g., a progress note) from the orderingprovider documenting the treating physician had intended the clinical diagnostic test be performed. In addition, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81, however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11 or from a Skilled Nursing Facility place of service 31. Based on this information, we decided that Medicare rules for coverage of the Covid testing have not been met. Therefore, we decided that the Plan does not have to pay forthe Covid testing provided on August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 2 retainer crowns (D6750) and the pontic (D6240) provided on October 22, 2020.You asked the Plan to pay forthe dental services. You say that the services were previously approved. You say that you cannot afford to pay for the services out of pocket. You say that you did not receive notification that you had reached the $1,000maximum benefit. You also say that you were not informed that the services would cost more than $1,000.The Plan denied your request. The Plan says there is an annual maximum benefit of $1,000 for covered dental services. The Plan also says the annual maximum has been exceeded.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 the services are listed as covered, the annual maximum benefit of $1,000 has been exceeded.The record shows that the Plan paid $72.80 towards dental services that you received on February 11, 2020 and $927.20 for dental services that you receive on February 18, 2020, thus exhausting your maximum benefit of $1,000. The Evidence of Coverage clearly states that after the annual maximum is exhausted, any remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay forthe 2 retainer crowns (D6750) and the pontic (D6240) provided on October 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe inpatient hospital stay provided from August 11, 2020, to August 14, 2020.You asked the Plan to waive the coinsurance forthe inpatient hospital stay. You say that this claim should be covered in full between your insurance and Medicare. The Plan denied your request. The Plan says you received authorized inpatient care at an out-of-network hospital and the claim was processed at the network levelThe 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 5% of the total cost per admission. You have been asked to pay $386.29 which is 5% of the allowed amount for the inpatient hospital stay. The allowed amount is $7,725.94. ($7,725.94 x 5% = $386.29). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. Thiscost 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 forthe inpatient hospital stay provided from August 11, 2020, to August 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance provided on January 27, 2020.You asked the Plan to payforthe periodontal maintenance. You say that you would like the Plan to pay the cost of a routine dental prophylaxis instead of the cost of the periodontal cleaning.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 forthe periodontal maintenance provided on January 27, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe testing services rendered on March 18, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 95907, 95886, and 95999 are 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 95907 is nerve conduction studies; 1-2 studies. The definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). The definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT codes 95907, 95886, and 95999 are not supported in the medical record. Specifically, there is no documentation of 1-2 nerve conduction studies to support code 95907. There is no documentation of needle electromyography to support code 95886. The file shows that Train of Four testing was performed and there is a more appropriate code for these services; therefore, code 95999 is not supported.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 forthe testing services rendered on March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forophthalmology services (92250, 92235, 0509T) provided on August 20, 2020.You asked the Plan to pay forophthalmology services. You say that these services are supported in the records.The Plan denied your request. The Plan says these services were not billed with the correct diagnosis 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. The rules also say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral.  If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.We find that the billing of these services is not supported in the medical record. Specifically, these services were billed with the diagnosis codes H35.3211, H35.3221, which indicate right and left laterality. There is a more appropriate bilateral code for this condition. Based on this information, we decided that Medicare rules for coverage of ophthalmology services have not been met.Therefore, we decided that the Plan does not have to pay forophthalmology services (92250, 92235, 0509T) provided on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 2D oral/facial photographic image (D0350), periodontal scaling and root planing (D4341), and oral hygiene instructions (D1330) provided on September 24, 2020.You asked the Plan to pay for2D oral/facial photographic image, periodontal scaling androot planing, and oral hygiene instructions. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says these services are not covered under your supplemental dental benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe 2D oral/facial photographic image (D0350), periodontal scaling and root planing (D4341), and oral hygiene instructions (D1330) provided on September 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forsurgical services (28308) provided May 19, 2020.You asked the Plan to pay forsurgical services. You say that the services were medically necessary.The Plan denied your request. The Plan says the documentation does not support the services billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 28308 is Osteotomy, with or without lengthening, shortening, or angular correction, metatarsal; other than first metatarsal, each.Wefind that CPT code 28308 is not supported in the medical record. Specifically, the operative report documents a resection was performed on the right foot, fourth metatarsal head. There is a more appropriate CPT code for this procedure. Based on this information, we decided that Medicare rules for coverage of surgical services have not been met.Therefore, we decided that the Plan does not have to pay forsurgical services (28308) provided May 19, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approvethe crown for tooth #15. We decided that the Plan does not have to pre-approvethe crowns for teeth #10, 12 and 14. You asked the Plan to pre-approvethe crown for tooth #15. You say that your dentist advised that you have cavities under your existing bridges. You also say that you were advised that it needs to be replaced as you keep having recurring infections. The Plan says that the crowns are not medically necessary.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 for teeth #10, 12 and 14 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 for teeth #10, 12, 14 and 15.
We decided that the Planhas to pre-approvethe crown for tooth #15. Our reviewer says that the crown for tooth #15 is medically necessary. The reviewer found that the provided documentation indicates that tooth #15 has a very poor fit. The reviewer found that tooth # 15 has early decay. Therefore, the reviewer found that the crown for tooth #15 is medically reasonable and necessary.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 for tooth #15 has been met. Therefore, we decided that the Plan has to pre-approvethe crown for tooth #15. We also decided that the Plandoes not have to pre-approvethe crowns for teeth #10, 12 and 14.Our reviewer says that the crowns for teeth #10, 12,and 14 are not medically necessary. Our physician reviewer found the provided documentation does not indicate that teeth #12 and 14 have any particular defect that would compromise the integrity of the crowns. The reviewer found that the provided documentation indicates that tooth #10 does not have enough decay to warrant a new crown. Therefore, the reviewer found that teeth # 10, 12,and 14 would not require new crowns.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 for teeth #10, 12,and 14 have not been met. Therefore, we decided that the Plan does not have to pre-approvethe crowns for teeth #10, 12,and 14.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 toopen the case again, we will send you a letter
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on September
17, 2020, by a provider who has opted-out of Medicare.
You asked the Plan to pay for the periodontal maintenance. You say that you would like this claim reprocessed
and approved for payment. The Plan denied your request. The Plan says the provider who rendered the services
has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the
periodontal maintenance (D4910) provided on September 17, 2020, by a provider who has opted-out of
Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on March 24, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this type of provider is not payable for assistant surgeon services.
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 surgeon services provided on March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services (G0181) provided on August 31, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the enrollee was an inpatient at this time.The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. Welooked at the file and Medicare rules. The enrollee was under inpatient status when the services in question were provided. It is inappropriate to bill a home health visit while an enrollee is an inpatient. 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 forthe home health services (G0181) provided on August 31, 2020
Appeal type: Practitioner Services
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 from January 9, 2020, to February 13, 2020.
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 had network providers available who could have provided 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 from January 9, 2020, to February 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forDME and related supplies provided on May 8, 2020.You asked the Plan to waive the coinsurance forDME and related supplies. You say that you disagree with the charges because you were told the Plan would take care of 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 20% coinsurance for DME and related supplies. You received DME and related supplies on May 8, 2020. The allowed amount is $258 and 20% of that is $51.60. You have been asked to pay the total coinsurance amount of $51.60 for DME and related supplies. DME and related supplies fall within the DME and related supplies 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 forDME and related supplies provided on May 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 18 to August 24,
2020, by an OON provider.
You asked the Plan to pay for a telehealth visit. You say that authorization should not be needed under
telemedicine for payment of services rendered. The Plan denied your request. The Plan says rules for payment
have not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on August 18 to
August 24, 2020, by an OON provider.