Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neurology services (CPT 95999) provided to the enrollee on September 28, 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 train-of-four monitoring is bundled with intraoperative neuromonitoring, and therefore, not separately reportable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95999 is "unlisted neurological or neuromuscular diagnostic procedure." We 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the enrollee underwent a craniotomy and received neurophysiological monitoring including electroencephalography as well as somatosensory and transcranial motor evoked evoked potentials. Train of Four monitoring is included in motor evoked potential services. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for neurology services (CPT 95999) provided to the enrollee on September 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on October 7, 2020.

You asked the Plan to pay for the drug 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 code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee 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. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0482 provided on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services provided on December 31, 2020, by an
OON provider.
You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 injection services provided on December 31,
2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on January 19, 2021.
You asked the Plan to reimburse you for the eyeglasses. You say that do not understand why benefits have been denied, and you would like your request for reimbursement to be reconsidered since you have not used the benefit in 2021. The Plan denied your request. The Plan says the eyewear benefit of a $250 allowance was applied to the purchase, leaving you with a responsibility of $67.96. A reimbursement payment was sent to you on February 17, 2021.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the Plan reimbursed you $250 on
February 17, 2021 for the eyeglasses and you have a financial responsibility of $67.96. Therefore, we decided that the Plan does not have to reimburse you an additional amount for the eyeglasses provided on
January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 14, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for reline complete mandibular denture (chairside) (D5731) received January 11, 2021.
You asked the Plan to pay for the complete mandibular denture. You say that you assumed the dentures would be covered. The Plan denied your request. The Plan says, per your Evidence of Coverage (EOC), dentures are 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 Plan does not have to pay for reline complete mandibular denture (chairside) (D5731) received January 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and resin-based composite - one surface, anterior (D2330) provided December 1, 2020.

You asked the Plan to pay for the limited oral evaluation and the second filling. You say that you were told the provider was in-network The Plan denied your request. The Plan says a one-time exception has been made to re-process the claims as in-network, however the limited oral evaluation is not a covered service and only one resin-based composite is covered per calendar year.

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 composite restorations (fillings) once per calendar year.

Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation is not among those covered under this benefit. Additionally, the Plan provided documentation that one resin-based composite was covered; therefore, the second resin-based composite is not covered under your benefits. Thus, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and resin-based composite - one surface, anterior (D2330) provided December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you are appealing this denial. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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 you are not getting enough therapy and would like to
receive therapy several times per day to get back in shape. The Plan denied your request. The Plan says the
denial of authorization for IRF service is correct.

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 complexity of your nursing, medical, and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the record supports
a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation
services. Medically necessary care can be provided in a different level of care. There is not a reasonable
expectation that you 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide acute inpatient hospital care.

You asked the Plan to provide acute inpatient hospital care. You say that the enrollee has failed nonoperative
treatment. The Plan denied your request. The Plan says inpatient services are not medically necessary for the
approved total shoulder procedure.

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 provide acute inpatient hospital care. Our reviewer
says that the documentation does not support that inpatient services are medically necessary. Our physician
reviewer found detailed documentation is not evident regarding significant co-morbidities that would require a
pre-authorization for an inpatient stay versus an outpatient procedure, at the time. There is no compelling
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an
exception to guidelines. Therefore, the request for inpatient admission medically reasonable and necessary for
Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (e.g., total
shoulder)) (23472) is 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 acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to provide acute inpatient hospital care and arthroplasty, glenohumeral joint; total shoulder
(glenoid and proximal humeral replacement (e.g., total shoulder)) (23472).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET scan.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says a CT scan for surveillance can be recommended.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found that in this case, the enrollee has a history of transitional cell carcinoma of the bladder and renal pelvis treated in 2016. The enrollee has right sided abdominal pain and back pain that is intermittent and positional. The records indicate that a wide differential diagnosis is being considered. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (PWC).
You asked the Plan to pre-approve these services. You say that you have enough room to move in the PWC and it will help you take care of yourself. 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 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 you do not meet the criteria for coverage. Our physician reviewer found the records show that you have a personal mobility deficit that impairs the completion of mobility-related activities of daily living (MRADLs) in the home. The mobility deficit is not helped by a walker, cane, or manual wheelchair. While you may be able to safely operate the PWC, the records do not show that your home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the PWC. Also, it is not clear that the PWC would significantly improve your ability to participate in MRADLs. The PWC is therefore 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 power wheelchair (PWC).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the breast provided on
November 19, 2020.
You asked the Plan to waive the copayment for an ultrasound of the breast. You say that you disagree with the
increase in 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 $100
copayment for ultrasounds.
You have been asked to pay the allowed amount of $78.53, which is less than the $100 copayment for an
ultrasound of the breast. An ultrasound of the breast falls 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 an
ultrasound of the breast provided on November 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve routine transportation. You say that you need more transportation trips for
your appointments. The Plan denied your request. The Plan says the denial of authorization for additional
routine transportation is correct, because routine transportation beyond 24 one-way trips per year is not
covered.
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 24 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 routine transportation trips.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on November 20, 2020, to November 22, 2020.

You asked the Plan to waive the copayment for an emergency room visit. You say that you were admitted from the emergency room. You say that this copayment should be waived. 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 $50 copayment for emergency care. 

You have been asked to pay a $50 copayment for an emergency room visit. Evidence was provided to show that observation services were provided. Observation services can last multiple days; therefore, the correct copayment has been applied. An emergency room visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on November 20, 2020, to November 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted with COVID pneumonia. The enrollee is currently overloaded due to acute kidney injury and is receiving acute care services that have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving or services that only the LTACH can provide. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic analysis of cochlear implant
(92603) provided January 19, 2021.
You asked the Plan to waive the copayment for the diagnostic services. You say that at each appointment, you
were informed by the receptionist that there is no charge for your visit. You are seeking redress of excessive
facility copay charges that you were not informed of prior to switching plans. 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 $200
copay for other outpatient diagnostic tests (includes genetic testing).
You have been asked to pay $134.44 copay for the diagnostic services. The allowed amount of $134.44 was
less than the copay amount of $200, therefore you are responsible for the lesser amount. The diagnostic service
falls 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 the diagnostic analysis of cochlear implant (92603) provided January
19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2020, V2200) purchased on October 20, 2020.

You asked the Plan to pay for the eyeglasses. You say that you did not know that you could not use your benefit for two years to the day and feel that the Plan should make an exception. The Plan denied your request. The Plan says you used your vision benefit in November of 2018, which is less than the two years before that your benefit allows. This benefit is administered on a rolling calendar year from your last date of service.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $100 every two years for routine eyewear. The contract clearly states that this benefit is administered on a rolling calendar year since your last date of service. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2200) purchased on October 20, 2020.