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

We decided that the Plan does not have to pre-approve an excision of benign lesion (D7411).
You asked the Plan to pre-approve the excision of benign lesion. You say that you would like this service to be approved for coverage. The Plan denied your request. The Plan says this service is not covered under your benefit plan.
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 pre-approve an excision of benign lesion (D7411).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the percutaneous lysis of epidural adhesions provided on October 29, 2020.
You asked the Plan to pay for the procedure. The Plan denied your request. The Plan says this is 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 pay for the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that percutaneous lysis of epidural adhesions remains experimental at this time. More research is needed to show safety and efficacy of this procedure. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pay for the percutaneous lysis of epidural adhesions provided on October 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor provided on October 12, 2020.You asked the Plan to pay forthe glucose monitor. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order, a signed proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay forthe glucose monitor provided on October 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services.

You asked the Plan to pay for the surgical pathology services. The Plan denied your request. The Plan says prior authorization was not obtained.

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 surgical pathology services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services.

You asked the Plan to pay for the imaging services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. The services were billed with POS code 31, which indicates that the enrollee was in a Part A covered stay. If that were the case, then the setup and transport would not be billable to the plan by the provider, but by the SNF. This means that reporting POS code 31 is not appropriate. Based on this information, we decided that Medicare rules for coverage of the imaging services have not been met. Therefore, we decided that the Plan does not have to pay for the imaging services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric testing provided to the enrollee by an out-of-network provider.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services are available in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 psychiatric testing provided to the enrollee by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper and lower partial denture (D5213, D5214).

You asked the Plan to pre-approve the partial denture. You say that the service is medically necessary. The Plan denied your request. The Plan says the benefit for this type of denture has been exhausted.

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 benefit for partial dentures is exhausted at this time. Therefore, we decided that the Plan does not have to pre-approve an upper and lower partial denture (D5213, D5214).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the urgent care visit.

You asked the Plan to waive the copay for the services provided. You say that you went in for a Covid test. The Plan denied your request. The Plan says the claim processed 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 $30 copay for each Medicare-covered urgent care provider visit.

You have been asked to pay a $30 copay for the services provided. The services fall within the urgently needed 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 copay for the urgent care visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 19, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says authorization was not obtained prior to the services being rendered.

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 physician's services. 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 physician's services provided on August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360, comprehensive genomic profile (CGP) testing
provided on August 1, 2020, by an OON provider.

You asked the Plan to pay for the laboratory services. You say that you are appealing the decision that this test
is experimental/investigational and request processing of the claim as in network since you are the only service
provider for Guardant360. The Plan denied your request. The Plan says enrollee's must receive their medical
services from an in-network provider with the exception being urgent or emergent services. Non-emergent
services with non-contracted providers require prior authorization before services being rendered.

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 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, providers should use CPT code
81479 (used for the entire bundled multi-test panel) at this time.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for Guardant360, comprehensive genomic profile
(CGP) testing provided on August 1, 2020, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the lab services.

You asked the Plan to waive the copay for the lab services. You say that you confirmed that the lab services are
covered. The Plan denied your request. The Plan says the claim processed 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 $35
copay for lab services when provided in an outpatient hospital facility.

You have been asked to pay a $35 copay for the lab services. The services fall within the outpatient diagnostic
tests 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 copay for the lab services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2740) for tooth #13.

You asked the Plan to pre-approve the crown. You say that the crown is necessary for the enrollee. The Plan denied your request. The Plan says that the x-rays submitted do not show that the crown is 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 crown 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 crown. Our reviewer says that a crown restoration for tooth #13 to prevent further fracture and possible loss of the tooth meets the criteria for coverage. Our physician reviewer found the enrollee's dental record and radiographs indicate the presence of a fracture with symptoms upon biting pressure. Our physician reviewer also found that a crown restoration to prevent further fracture is reasonable and necessary in my opinion. 

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 crown have been met. Therefore, we decided that the Plan has to pre-approve a crown (D2740) for tooth #13.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for injections (64493) provided on September 15, 2020, and September 29, 2020.

You asked the Plan to waive the copayment for injections. You say that the Plan required you to get these services before another procedure so you should not be responsible for any charges. The Plan denied your request. The Plan says this processed 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 $40 copayment for physician specialist services. 

You have been asked to pay a $40 copayment for each date of service of injections, which are specialist services. 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 injections (64493) provided on September 15, 2020, and September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional extractions (D7210), a complete upper denture (D5110), a partial lower denture (D5214), 2 alveoloplasties (D7311), and gingival irrigation (D4291).

You asked the Plan to pre-approve 10 additional extractions, a complete upper denture, a partial lower denture, alveoloplasties, and gingival irrigation. You say that you were diagnosed with cancer. You say that that was the reason that you lost your teeth. You also say that these services should be covered. The Plan denied your request. The Plan says 1 extraction per year is covered. The Plan says that the frequency limit for this service has been exceeded. The Plan also says that dentures, alveoloplasties, and gingival irrigation are not 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 frequency limit of 1 extraction per year has been reached. The record shows that the Plan approved the extraction of tooth # 10. Additionally, dentures, alveoloplasties, and gingival irrigation are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 10 additional extractions (D7210), a complete upper denture (D5110), a partial lower denture (D5214), 2 alveoloplasties (D7311), and gingival irrigation (D4291).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the outpatient surgery services.

You asked the Plan to waive the copay for the services provided. You say that you were unaware of the pricing.
The Plan denied your request. The Plan says the claim processed 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 20%
coinsurance for outpatient surgery.

You have been asked to pay a 20% coinsurance for the services provided. The services fall within the
outpatient surgery 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 copay for the outpatient surgery
services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.

You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is 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 a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is status post fall in March 2020 resulting in a compression fracture deformity of the fifth lumbar vertebrae which resulted in spondylolisthesis and spinal stenosis causing neurogenic claudication. The Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. Open laminectomy is the gold standard for treatment of spinal stenosis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from December 3, 2019 to December 30, 2019.

You asked the Plan to pay for home health 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. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, these services were billed with an incorrect type of bill code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from December 3, 2019 to December 30, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the urgent care services.

You asked the Plan to waive the copay for the services provided. You say that you may have been exposed to COVID. The Plan denied your request. The Plan says the claim processed 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 $45 copay for each Medicare-covered urgent care provider visit.

You have been asked to pay a $45 copay for the services provided. The services fall within the urgently needed 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 copay for the urgent care services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids.

You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says out-of-network hearing aids 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 provided by an in-network provider.

We looked at the file and the Plan's rules. The records show that the hearing aids were provided by a provider who is not in the Plan's vendor network. The Plan does not covered out-of-network hearing aids. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 molecular pathology testing.

You asked the Plan to pay for the Guardant360 molecular pathology testing. 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 the Guardant360 molecular pathology testing is not supported in the medical record. Specifically, this service should be billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the Guardant360 molecular pathology testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 molecular pathology testing.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a HHA.

You asked the Plan to pre-approve the HHA. The Plan denied your request. The Plan says a HHA in the absence of skilled nursing needs is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the HHA have not been met. Therefore, we decided that the Plan does not have to pre-approve a HHA.