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

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 14, 2021.
You asked the Plan to pay for a limited oral evaluation. You say that the service should be covered. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of 2 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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit for oral evaluations. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for arthroplasty provided from December 11, 2019, to December 18, 2019.
You asked the Plan to waive the coinsurance for arthroplasty. You say that you thought you would only owe a few hundred dollar copayment and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities. You received arthroplasty at an outpatient hospital facility from December 11, 2019 to December 18, 2019. Arthroplasty is considered an outpatient surgical procedure. Therefore, you are responsible to pay $7,351.47, which is less than the 20% coinsurance amount.
You have been asked to pay the total coinsurance amount of $7,351.47 for arthroplasty. Arthroplasty falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 arthroplasty provided from December 11, 2019, to December 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87541, 87581, 87631, 87640, and 87798 provided on July 16, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 87486, 87496, 87498, 87541, 87581, 87631, 87640, and 87798 are 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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87541, 87581, 87631, 87640, and 87798 provided on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be rendered by the out-of-network (OON) providers.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested providers in this case are not network providers with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be rendered by the out-of-network (OON) providers.
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 service is medically necessary. The Plan denied your request. The Plan says the service 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital and does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. 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. Specifically, medically necessary services are being obtained at the enrollee's current level of care. This means admission into a LTACH is not
medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740), and a core buildup (D2950) provided on May 5, 2021.
You asked the Plan to pay for a crown, and a core buildup. You say that the services should be covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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 a crown (D2740), and a core buildup (D2950) provided on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction services provided on April 19, 2021.
You asked the Plan to pay for the refraction services. You say that the eye refraction was performed by the same doctor who operated on your eyes. The Plan denied your request. The Plan says the claim processed correctly.
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. We looked at the file and the Plan's rules. In this case, the eye refraction services were not provided as part of a routine eye exam. Based on this information, we decided that the Plan's rules for coverage of refraction services have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction services provided on April 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.
You asked the Plan to pre-approve radiofrequency ablation. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has bilateral sacroilitis. The enrollee takes Gabapentin for pain. The enrollee had bilateral sacroiliac joint injections on April 23, 2020 which produced 100% pain relief and on May 7, 2021 which produced 80% pain relief for one week. The request is considered experimental/ investigational because of the wide variation in efficacy reported in the literature. Therefore, the request is considered 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar interspinous device implantation.
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870). You say that the enrollee needs this procedure. The Plan denied your request. The Plan says Medical studies haven't proven that the device is helpful for treatment of the enrollee's health problem.
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 insertion of interlaminar/interspinous
process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic pain from spinal stenosis with neurogenic claudication. The record indicates that imaging has demonstrated multi-level disease including moderate to severe spinal stenosis at L2-L3 and severe spinal stenosis at L3-L4, the levels requested for treatment. The record does not indicate that surgical treatment at more than two levels is not required. The elements of the coverage criteria 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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar interspinous device implantation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), topical application of fluoride varnish (D1206), and periodontal maintenance (D4910) provided September 2, 2020.
You asked the Plan to pay for the periodic oral exam, fluoride varnish and periodontal maintenance. You say that you do not believe the Plan's denial is accurate. The Plan denied your request. The Plan says you used your maximum dental allowance prior to the services and therefore they are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers non-Medicare-covered preventative and comprehensive dental services up to $200 every year.
We looked at the file and Medicare rules. The Plan provided documentation that the full $200 dental benefit
was applied to your dental services on May 20, 2020. Based on this information, we decided that the Plan does
not have to pay for the periodic oral evaluation - established patient (D0120), topical application of fluoride
varnish (D1206), and periodontal maintenance (D4910) provided September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a therapeutic parenteral drug (D9610), and an unspecified preventive procedure (D1999) provided on December 31, 2020.
You asked the Plan to pay for a therapeutic parenteral drug, and an unspecified preventive procedure. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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 a
therapeutic parenteral drug (D9610), and an unspecified preventive procedure (D1999) provided on December 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for next generation sequencing testing provided on March 11, 2021.
You asked the Plan to pay for genetic testing. You say that this testing was ordered by the enrollee's treating physician to help determine the best course of treatment. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the enrollee was tested with the same test for the same primary cancer diagnosis on April 13, 2020.
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing testing may be covered under certain circumstances, including that the enrollee has not been previously tested with the same test using NGS for the same cancer genetic content. We looked at the file and Medicare rules. The enrollee was previously tested with the same test using NGS for the same cancer genetic content on April 13, 2020. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for next generation sequencing testing provided on March 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the rotary wing air transport (A0431), and the rotary wing air mileage, per statute mile (A0436) provided on January 17, 2021.

You asked the Plan to pay for the air ambulance. You say that the services were medically necessary. The Plan denied your request. The Plan says the ambulance services were not medically necessary.

The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 

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 air ambulance. Our reviewer says that the air ambulance transport is not medically necessary. Our physician reviewer found the provided documentation does not show that the enrollee was medically unstable or met trauma criteria. The reviewer found that there is no evidence the enrollee had been medically evaluated and determined to need services that were not available locally. The reviewer found that even if the enrollee or their family preferred them to go to the larger acute care hospital (ACH), the enrollee was medically stable and could have been transported by ground ambulance. Therefore, the reviewer found that the use of an air ambulance was not medically necessary or reasonable. 

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 air ambulance have not been met. Specifically, the file indicates the enrollee was not medically stable and could have been transported by ground ambulance. Therefore, we decided that the Plan does not have to pay for the rotary wing air transport (A0431), and the rotary wing air mileage, per statute mile (A0436) provided on January 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan has to pre-approve periodontal scaling and root planing (D4341) in all four quadrants.
You asked the Plan to pre-approve periodontal scaling and root planing (D4341). The Plan denied your request. The Plan says that there is not a minimum of four teeth affected in the quadrant therefore, the criteria for coverage has not been met.
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 periodontal scaling and root planing (D4341) 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 periodontal scaling and root planing (D4341). Our reviewer says that the provided radiographs indicate each of the quadrants appear to have at least four teeth with notable bone loss. Our physician reviewer found that given the radiographic presentation of the teeth in question, there would be medical necessity for scaling and root planing in four quadrants. 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 periodontal scaling and root planing (D4341) have been met. Therefore, we decided that the Plan has to pre-approve periodontal scaling and root planing (D4341) in all four quadrants.
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 service is medically necessary. The Plan denied your request. The Plan says the service 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital and does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. 

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. Specifically, medically necessary services are being obtained at the enrollee's current level of care and they do not require any additional services. This means admission into a LTACH is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on May 5, 2021.
You asked the Plan to pay for the dental services. You say that you had surgery to open your gums so they could remove the nerve. You say that you do not agree with the denial of reimbursement. The Plan denied your request. The Plan says the service is 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 the dental services provided on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic casts (D0470), and a complete lower denture (D5120) provided from February 26, 2021, through March 2, 2021.
You asked the Plan to pay for diagnostic casts, and a complete lower denture. You say that you lost your denture and needed a replacement. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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 diagnostic
casts (D0470), and a complete lower denture (D5120) provided from February 26, 2021, through March 2, 2021.