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

We decided that the Plan has to pre-approve retainer crowns for tooth #'s 2 & 4 and a pontic for tooth #3.
You asked the Plan to pre-approve the retainer crowns and pontic. You say that a fixed bridge is the ideal treatment to replace tooth #3 because it is the only missing functional tooth in the enrollee's mouth. You also say that the fixed bridge abutment will restore tooth #4 as needed and replace the missing tooth #3. The Plan denied your request. The Plan says that the services 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 retainer crowns and pontic 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 retainer crowns and pontic. Our reviewer says that the services are medically necessary. Our physician reviewer found tooth #4 requires a crown to restore it to normal functional integrity (due to the fractured lingual cusp). Our reviewer also found that replacing the missing tooth #3 via a fixed bridge is reasonable rather than a removable appliance. 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 retainer crowns and pontic have been met. Therefore, we decided that the Plan has to pre-approve retainer crowns for tooth #'s 2 & 4 and a pontic for tooth #3.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
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 admission to a LTACH is not medically necessary. Our physician reviewer found the
enrollee is quadriplegic secondary to C-spine injury status post a motor vehicle accident with multiple wounds
and has had multiple procedures. Had period of shock requiring pressors, now hemodynamically stable.
LTACH requested and denied based on condition of wounds and overall health status not requiring that level of
care.
Based on the documentation provided, the enrollee does not meet criteria for LTACH admission. The enrollee
has wounds that are improving. No other services are needed that would require LTACH level of care. Unless
the degree of management of wounds has not been correctly stated, this does not appear to meet criteria for
LTACH admission and the enrollee does not appear to need another 25 days prior to discharge to lower level of
care than LTACH.
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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the diagnostic tests provided by facility.
You asked the Plan to waive the coinsurance for the diagnostic tests. You say that you have met your
deductible. You say that you want the amount you owe clarified. The Plan denied your request. The Plan says
the coinsurance applied 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 5%
coinsurance for each in-network outpatient hospital visit for diagnostic tests.
You have been asked to pay a total of $90.37 for the diagnostic tests.
Service Allowed Amount Coinsurance Member Liability
Myocardial Imaging $1,327.42 5% $66.37
Echocardiography $480.09 5% $24
TOTAL: $90.37
The diagnostic tests 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 coinsurance for the diagnostic tests provided by the facility.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on November 14,
2019.
You asked the Plan to waive the copayment for the CT scan. You say that you should not be responsible for the
cost because the CT scan was unnecessary. The Plan denied your request. The Plan says the $437.77 deductible
amount was removed and a $200 copayment was applied towards the member's liability.
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 $200
copayment for each advanced imaging service (e.g., MRI, CT, and PET scan, nuclear medicine, and stress
tests).
You have been asked to pay a $200 copayment for the CT scan. The CT scan 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 CT scan provided on November 14, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered to enrollee on September 13, 2019.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 services 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 99284 is Level 4 emergency department visit. The definition of code 99285 is Level 5 emergency department visit.We find that CPT codes 99284 and 99285 are not supported in the medical record. Specifically, two ER visits were billed on the same date and the second service was not billed with condition code G0 indicating multiple medicalvisits occurred on the same date. 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 emergency room (ER) services rendered to enrollee on September 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDx-Melanoma testing rendered to the enrollee on October 28, 2019.
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 services are not covered.
The Plan must follow Medicare rules. Medicare rules say that DecisionDx-Melanoma testing is covered when specific criteria are met.
We looked at the file and Medicare rules. The file shows that the enrollee does not meet the criteria for coverage of the testing, as the tumor was staged at least T3a and depth was greater than 2.6 millimeters. 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 for the DecisionDx-Melanoma testing rendered to the enrollee on October 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 15, 2019 to April 24, 2019 to the enrollee by an out of network (OON) provider. 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 services were rendered by a non-participating provider without 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 has network providers available who can provide 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 February 15, 2019 to April 24, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for needle electromyography (95861) and continuous intraoperative neuromonitoring (G0453). We decided that the Plan does not have to pay for neuromuscular junction testing (95937).You asked the Plan to pay for needle electromyography (95861), neuromuscular junction testing (95937) and continuous intraoperative neuromonitoring (G0453). You say that you would like reconsideration based on the records submitted. The Plan says that the documentation submitted does not support the services billed.We decided that the Plan has to pay forneedle electromyography (95861) and continuous intraoperative neuromonitoring (G0453).We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request. Our reviewer says that CPT 95861 should be paid. The documentation indicates that EMG monitoring of both lower extremities was performed. Our physician reviewer found CPT G0453 should be paid. The documentation supports that five hours and twenty-five minutes of professional oversight from outside of the OR was provided. G0453 is not an add-on code to CPT 95937, as argued by the Plan.Therefore, we decided that the Plan has to pay for needle electromyography (95861) and continuous intraoperative neuromonitoring (G0453). We also decided that the Plan does not have to pay for neuromuscular junction testing (95937).We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request. Our reviewer says that CPT 95937 should be denied. There is no evidence that neuromuscular junction testing was performed.Train of Four monitoring is not considered neuromuscular junction testing.Therefore, we decided that the Plan does not have to pay for neuromuscular junction testing (95937).If the Plandoes 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 Plandoes not haveto pay fornail trimming and cutting services received from December 18, 2018 to October 29, 2019.You asked the Planto pay forthe services. You say that without routine foot care, your foot may eventually have to be amputated.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. Records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fornail trimming and cutting services received from December 18, 2018 to October 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe nitroglycerin spray provided on October 28, 2019.You asked the Plan to pay forthis drug. The Plandenied your request. The Plan says that self-administered drugs are not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forthe nitroglycerin spray provided on October 28, 2019.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete mandibular denture provided on November 25, 2019.
You asked the Plan to pay for the complete mandibular denture. You say that the price of $1,800 is too high for a lower plate. You also say that the provider lost or messed up on your impression and you should not have to pay for another one. The Plan denied your request. The Plan says this service exceeded the $500 annual maximum payout for dental services for plan year 2019.
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 Plan offers a $500 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on August 15, 2019 and your annual maximum benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the complete mandibular denture provided on November 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered onlywhen 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 there is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided at a skilled nursing facility (SNF) level.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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete maxillary denture and complete mandibular denture provided on October 29, 2019.You asked the Plan to pay forthe complete maxillary and mandibular dentures. You say that your first dentures were too big for your mouth.The Plan denied your request. The Plan says these services exceed the maximum allowed per period.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, complete dentures are limited to one procedure every five years. The record shows that you received complete dentures on January 9, 2018 and your complete dentures benefit is now exhausted.Therefore, we decided that the Plan does not have to pay forthe complete maxillary denture and complete mandibular denture provided on October 29, 2019.Your complaint about being dissatisfied with the dentist who provided your first set of dentures 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe CT scan provided on November 19, 2019.You asked the Plan to waive the copayment forthe CT scan. You say that you were not advised you had a $50 copayment responsibility.The Plan denied your request. The Plan says the copayment applied 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 $50 copayment for a Medicare-covered diagnostic CAT Scan at a freestanding provider. You have been asked to pay a $50 copayment for the CT scan. The CT scan 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 forthe CT scan provided on November 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe cystoscopy provided on December 3, 2019.You asked the Plan to waive the copayment forthe cystoscopy. You say that you do not agree with this amount you have to pay for a minor procedure. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees inclear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for an Outpatient Hospital Facility. You have been asked to pay a $325 copayment for the cystoscopy. The cystoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient and ambulatory surgical center" benefit category. The record shows you had the procedure done at an outpatient hospital.Thismeans 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 forthe cystoscopy provided on December 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy (S9328) provided on April 30, 2019 through June 18, 2019.You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says S codes are not payable by Medicare so payment for CPT code S9328 is not a covered benefit.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 S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on April 30, 2019 through June 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on March 21, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe provided services. You say that the authorization approval can be very confusing.The Plan denied your request. The Plan says the medication was to be obtained through a specialty pharmacy.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 authorization clearly states the conditions of the approval. The Plan did not pre-approve the services for the provider 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 forthe medical services provided on March 21, 2019 by an out of network (OON) provider.