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

We decided that the Plan does not have to pre-approve an initial 15 minutes of general sedation (D9222), 2 additional 15 minutes of general sedation (D9223), a therapeutic drug injection (D9612), 10 extractions (D7140), and 2 implants (D6010).
You asked the Plan to pre-approve the dental services. You say that you have sjogren's syndrome. You say that this diagnosis is causing your teeth to decay rapidly. You say that you need your teeth extracted. You also say that you do not want to be in any more pain. The Plan denied your request. The Plan says anesthesia, therapeutic drug injection, extractions, and implants are not listed as covered services.
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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an initial 15 minutes of general sedation (D9222), 2 additional 15 minutes of general sedation (D9223), a therapeutic drug injection (D9612), 10 extractions (D7140), and 2 implants (D6010).
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 November 27, 2019.
You asked the Plan to pay for the orthosis. The Plan denied your request. The Plan says that the billed supply code cannot be verified. 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 pay for the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. The documentation does not support that the lumbar sacral orthosis was prescribed for one or more of the covered indications in this case, as the back examination in the medical records documented normal range of motion of the spine, and no tenderness. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for the orthosis. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on November 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on November 1, 2019 and November 5, 2019.You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 Plandid not pre-approve the drug test.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 a drug test provided on November 1, 2019 and November 5, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code A4550 provided on December 18, 2019.
You asked the Plan to pay for CPT code A4550. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says CPT code A4550 remains unsupported as it is an unbundled service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare specifically says that CPT code A4550 is always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of CPT code A4550 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code A4550 provided on December 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on November 18, 2019.
You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says no medical records were received to support the diagnosis on the submitted order, therefore the billed codes cannot be supported.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at this the file and Medicare rules. There are no medical records supporting medical necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthoses
(L1833) and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on November 18, 2019.
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 on October 23, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
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 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 on October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive dental procedures, inhalation of nitrous
oxide/analgesia, extraction, complete maxillary denture, panoramic x-ray, and comprehensive oral evaluation
provided by an OON provider on December 9, 2019.
You asked the Plan to pay for the dental services. You say that you were told by a plan representative that this
provider was in-network. The Plan denied your request. The Plan says this dentist is an OON provider. The
Plan also says that these services are not covered services when performed by an OON provider.
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
covered when they are received by an OON provider. Therefore, we decided that the Plan does not have to pay
for the adjunctive dental procedures, inhalation of nitrous oxide/analgesia, extraction, complete maxillary
denture, panoramic x-ray, and comprehensive oral evaluation provided by an OON provider on December 9,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code 51700 provided on July 25,2019.You asked the Plan to pay forCPT code 51700. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the records do not support the billing of CPT code 51700.The Plan mustfollow 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 51700 is Bladder irrigation, simple, lavage and/orinstillation.We find that CPT code 51700 is not supported in the medical record. Specifically, the medical records provided do not show that bladder irrigation, simple, lavage and/or instillation was performed. Based on this information, we decided thatMedicare rules for coverage of CPT code 51700 have not been met.Therefore, we decided that the Plan does not have to pay forCPT code 51700 provided on July 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex spacer.
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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have back pain and lumbar spinal stenosis (narrowing of the spine). The requested Vertiflex spacer is considered experimental, as more research is needed to support effectiveness. The services are 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 Vertiflex spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physician services rendered to you from November 12, 2019 to January 28, 2020.
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayments were 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 $10 copayment for each primary care doctor visit for Medicare-covered services.
Review of the file shows that you had primary care physician (PCP) services on 11 dates of service from November 12, 2019 to January 28, 2020. You have been asked to pay a $10 copayment per date of service for these services, for a total of $110. These services fall within the each primary care doctor visit for Medicare-covered services 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 copayments for the physician services rendered to you from November 12, 2019 to January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on November 8, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you saw a nurse practitioner and should owe a lesser copayment. 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 $45 copayment for each specialist visit. You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the platelet-rich plasma injections rendered on September 30, 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. The rules say that procedure code 0232T is denied as not medically necessary. We looked at the file and Medicare rules. The services at issue are platelet-rich plasma injections billed with code 0232T. These services are denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pay for the platelet-rich plasma injections rendered on September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for various services received from May 23, 2019 to June 24, 2019. You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the services were provided by out-of-network providers. 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 various services received from May 23, 2019 to June 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the Nursing Facility Visit
You asked the Plan to pay for the nursing facility care. You say that services were medically necessary. The Plan denied your request. The Plan says the services were not preauthorized. The enrollee was under private pay at the time services were rendered. There were network providers who could provide the services at issue.
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 Nursing Facility Visit
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on December 13, 2019.
You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says no medical records were received to support the diagnosis on the submitted order, therefore the billed codes cannot be supported.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There are no medical records supporting medical necessity. Based on this information, we decided that Medicare rules for coverage of the knee orthoses (L1833) and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on December 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance (D4910) provided on December 11, 2019.You asked the Plan to pay forthe dental service. You say that you had a normal cleaning, not periodontal maintenance, as far as you knew. You say that you were not advised that there would be a different charge.The Plan denied your request. The Plan says periodontal maintenance is covered at 50%.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 periodontal maintenance is a covered service, there is a 50% coinsurance. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverageTherefore, we decided that the Plan does not have to pay forthe periodontal maintenance (D4910) provided on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 64495 provided on October 25, 2019.
You asked the Plan to pay for CPT code 64495. You say that the medical records support the billing of CPT code 64495. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 64495.
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 64495 is Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary 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 CPT code 64495. Our reviewer says that the medical records do not support the billing of CPT code 64495. Our physician reviewer found the member was seen on 10/07/2019. She was having intermittent episodes of axial back pain. She had undergone bilateral medial branch blocks with more than 3 months of 80% pain relief and her pain was returning. She had pain rated at 5/10. Physical examination findings included obesity with a body mass index of 38. She had bilateral facet joint tenderness. There was pain with facet loading maneuver. The treatment plan included confirmatory lumbar medial branch blocks. On 10/25/2019 she was seen for bilateral lumbar medial branch blocks. The blocks were done at the L3, L4, and L5 medial branches and intended to block the L3/4, L4/5, and L5/S1 facet joints. The coding billed is incorrect. Blocks done at the L3, L4, and L5 medial branches would block the L4/5 and L5/S1 facet joints. This is a two-level, not three level procedure. Blocking the L3/4 facet joint would have required adding a block at L2.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 64495 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 64495 provided on October 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 13, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says there are no progress notes from the ordering provider.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on December 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete maxillary denture (D5110) and a mandibular partial denture (D5214).
You asked the Plan to pay for the complete maxillary denture and mandibular partial denture. You say that the enrollee can no longer wear his bottom partial denture. The Plan denied your request. The Plan says these services exceed the maximum count 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 and partial dentures are limited to one procedure every five plan years. The record shows that the enrollee received a complete maxillary denture on December 1, 2017 and a mandibular partial denture on March 2, 2018 and your complete dentures and partial dentures benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for a complete maxillary denture (D5110) and a mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 14, 2020 by an out of network (OON) provider. You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says that the claim processed correctly. 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 14, 2020 by an out of network (OON) provider.