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

We decided that the Plan does not have to pre-approve surgical extractions (D7210 x 3), intravenous sedation
(D9239), and an additional 15 minutes of intravenous sedation (D9243 x 3).

You asked the Plan to pre-approve the dental services. You say that you were attacked. You say that you are
not able to eat solid food. The Plan denied your request. The Plan says the dental services that you requested
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 extractions and
intravenous sedation are not among those covered under this benefit. The Evidence of Coverage states that
additional coverage for preventive and comprehensive dental services can be provided through the plan's Flex
Benefit. Reimbursement for dental services is limited to the annual maximum under the Flex benefit. The
record shows that the flex benefit has been exhausted. Therefore, we decided that the Plan does not have to 
pre-approve surgical extractions (D7210 x 3), intravenous sedation (D9239), and an additional 15 minutes of
intravenous sedation (D9243 x 3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on November 24, 2020.
You asked the Plan to pay for the dental services. You say that the claim, along with the Evidence of Coverage do not make sense. You say that the simple exam that you received allowed the dentist to prescribe you an antibiotic. You also say that you were never provided with an Evidence of Coverage. The Plan denied your request. The Plan says the services that you received 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 services you received are not among those covered under this benefit. Additionally, the record shows that you did not elect to purchase the option supplemental benefits prior to the date of service. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (99100) provided on September 29, 2020.
You asked the Plan to pay for anesthesia services. You say that this should be covered. The Plan denied your request. The Plan says this cannot be separately paid.
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 99100 is not supported in the medical record. Specifically this code has a status code of "B." Payment for this service is always bundled into payment for other services. Based on this information, we decided that Medicare rules for coverage of anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99100) provided on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction provided on December 1, 2020.
You asked the Plan to pay for the extraction. You say that Plan representatives advised that you could be seen by any provider. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective April 1, 2013, to April 1, 2021. The Plan also says that you did not contact the Plan prior to receiving the service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the extraction provided on December 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the endovenous ablation rendered on July 2, 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 procedure code 36475 is 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 36475 is endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated. We find that CPT code 36475 is not supported in the medical record. Specifically, there is no documentation of endovenous albation therapy of an incompetent vein of the extremity with image guidance and monitoring. 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 endovenous ablation rendered on July 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram, routine ECG provided on
December 26, 2020.
You asked the Plan to pay for the electrocardiogram, routine ECG. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 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 an electrocardiogram, routine ECG provided on
December 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no qualifying diagnosis for a group 3 power wheelchair.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the physician document notes normal strength and movement of all extremities, which is in contrast to the PT wheelchair evaluation note which states the enrollee cannot use a manual wheelchair due to upper extremity weakness. The enrollee does not have a diagnosis for a Group 3 chair as there is no evidence of myopathy, neurologic disease, or congenital skeletal deformity based on the physician progress reports.
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 pre-approve a group 3 power wheelchair and accessories for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 15, 2020.
You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 15, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on October 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 1, 2020.
You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place by the medics and triaged to BLS. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 1, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid purchased from an out-of-network provider.

You asked the Plan to pay for the hearing aid. You say that the plan should pay for the hearing aid obtained from an out of network provider. The Plan denied your request. The Plan says hearing aids ordered through providers other than the Plan's Hearing are not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are obtained from an in-network provider. 

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 hearing aid have not been met. Specifically, the hearing aids at issue were not purchased from the Plan's Hearing benefit vendor. Therefore, we decided that the Plan does not have to pay for the hearing aid purchased from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397).
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were medically necessary. The Plan denied your request. The Plan says the medical records do not support the items billed.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to criteria listed 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 pay for the knee orthosis and suspension sleeve. Our reviewer says that the items provided were not medically necessary and reasonable. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, cone beam CT capture and interpretation, cone beam CT image capture for TMJ series, and retreatment of previous root canal therapy provided on May 22, 2020 by an OON provider.
You asked the Plan to pay for the problem focused limited oral evaluation, cone beam CT capture and interpretation, cone beam CT image capture for TMJ series, and retreatment of previous root canal therapy. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that services are only covered by your Health Plan for in-network dentists.
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 OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, cone beam CT capture and interpretation, cone beam CT image capture for TMJ series, and retreatment of previous root canal therapy provided on May 22, 2020 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services rendered.

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 provider type is not covered.

The Plan must follow Medicare rules. The rules say that Medicare makes payment for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, PA, NP, or CNS.

We looked at the file and Medicare rules. The file shows that the assistant surgeon is not a physician, PA, NP, or CNS. 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 assistant surgeon services rendered.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Tempus nP testing (81479) provided on August 10, 2020.
You asked the Plan to pay for Tempus nP testing. You say that this testing was ordered to guide treatment decisions. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that diagnostic laboratory tests using next generation sequencing (NGS) must have FDA-approval or clearance and results provided to the treating physician for management of the patient using a report template to specify treatment options. We looked at the file and Medicare rules. The record shows that the testing at issue does not have FDA approval or clearance. Based on this information, we decided that Medicare rules for coverage of Tempus nP testing have not been met. Therefore, we decided that the Plan does not have to pay for Tempus nP testing (81479) provided on August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite.

You asked the Plan to pay for the resin-based composite. You say that you thought this service would be covered. The Plan denied your request. The Plan says the calendar year maximum had been reached.

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 $1,500 combined allowance for supplemental preventive and comprehensive services every year. The contract says that you are responsible for any amount over and above the allowance amount. The record shows that you met the annual maximum benefit while processing this claim and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composite.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the Centers for Medicare & Medicaid Services (CMS) established defining criteria for a LTACH admission. The Plan denied your request. The Plan says the requested LTACH services are not medically necessary, reasonable, or appropriate for the diagnosis and condition of the enrollee at this time.

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 does not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that there are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Our physician reviewer also found that this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more appropriate for SNF.

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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says ongoing medical and functional services can be safely rendered by outpatient services.

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 the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. The enrollee is at a high functional level and the documentation does not support that the patient requires ongoing multiple therapies at an IRF 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-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transurethral destruction of prostate tissue.
You asked the Plan to pre-approve transurethral destruction of prostate tissue. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested services.
The Plan must follow Medicare rules. Medicare rules say that transurethral destruction of prostate tissue is covered for enrollees less than or equal to 80 years old and a prostate volume of 30-150 cubic centimeters. We looked at the file and Medicare rules. Review of the file shows that you are not less than or equal to 80 years old and your prostate volume is 27.58 cubic centimeters. Based on this information, we decided that Medicare rules for coverage of transurethral destruction of prostate tissue have not been met. Therefore, we decided that the Plan does not have to pre-approve transurethral destruction of prostate tissue.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital observation provided on February 23, 2020.
You asked the Plan to waive the copayment for the outpatient hospital observation. You say that you should not have been kept for observation and you should have been admitted as an inpatient. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $325 copayment for in-network outpatient hospital observation services. You have been asked to pay a $325 copayment for the outpatient hospital observation. The outpatient hospital observation falls within the "Outpatient Hospital Observation" 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 outpatient hospital observation provided on February 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cystostomy tube change and office visit provided by an out-of-network provider on August 27, 2020.
You asked the Plan to pay for the cystostomy tube change and office visit. You say that you are appealing the denied claim. The Plan denied your request. The Plan says care received from an out-of-network provider will not be covered.
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 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 cystostomy tube change and office visit provided by an out-of-network provider on August 27, 2020.