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

We decided that the Plan has to pre-approve a crown (D2740) for tooth #30.
You asked the Plan to pre-approve the crown. You say that the crown to root ratio is excellent for tooth #30.
You also say that tooth #30 will need a core buildup and a crown to restore health and function. The Plan
denied your request. The Plan says that the documentation shows there is furcation involvement (involvement
at a branching point of the tooth root). The Plan also says that this finding results in a poor long-term prognosis
for this tooth.
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 the
documentation provided meets the criteria for coverage for a crown restoration (D2740) for tooth #30. Our
physician reviewer found the dental record and radiographs indicate that tooth #30 has a large restoration with
recurrent caries. Our reviewer found that the bone support appears adequate for good long term prognosis. Our
physician reviewer also found that a crown restoration is medically reasonable and necessary to return tooth
#30 to good occlusal function.
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 preapprove
a crown (D2740) for tooth #30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetes supplies provided on September 9, 2020.

You asked the Plan to pay for the diabetes supplies. The Plan denied your request. The Plan says per the enrollee's Evidence of Coverage, the health Plan exclusively covers diabetic supplies made by the Plan's diabetes supply provider.

The Plan must follow Medicare rules. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan requires diabetes supplies to be provider by the Plan's 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 diabetes supplies have not been met. Therefore, we decided that the Plan does not have to pay for diabetes supplies provided on September 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on September 23, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you would not have received the services if you knew that you would owe a 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 $275 copayment for ambulance services. You have been asked to pay a $275 copayment for ambulance services. Ambulance services fall within the ambulance 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 copayment for ambulance services provided on September 23, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT of the head/brain and extremity study provided on August 18, 2020.
You asked the Plan to pay for the CT of the head/brain and extremity study. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on August 6, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the CT of the head/brain and extremity study provided on August 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on August 31, 2019.

You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that you did not receive proper notice of the enrollee's benefit determination, which resulted in the untimely submission of this claim. The Plan denied your request. The Plan says all claims are subject to timely filing within one year (12 months) from the date the services were furnished. The Plan also says that the original claim has a processed date of September 13, 2019, and the corrected claim was received on October 20, 2020, which is past the allowed 12 month time frame.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the psychiatric diagnostic evaluation was not filed until October 9, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on August 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent
basis on an outpatient, in a long-term care facility, or at the home with home health services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nursing care in home by a registered nurse for 14 hours per day.
You asked the Plan to pre-approve a home health services. You say that you feel the home health services are medically necessary. You say that these services will help you to maintain a normal healthy lifestyle. The Plan denied your request. The Plan says the requested service is not covered.
The Plan must follow Medicare rules. Medicare rules say that procedure code S9123 is not valid for Medicare purposes and is not payable. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home health aide have not been met. Therefore, we decided that the Plan does not have to pre-approve nursing care in home by a registered nurse for 14 hours per day.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the Home health aide or certified nurse assistant, providing
care in the home; per hour (S9122 x 203) provided from January 5, 2020, to January 21, 2020.
You asked the Plan to pay for the home health services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the documentation submitted did not sufficiently support coverage
criteria for the billed service. The Plan also says that the provider is not Medicare certified and therefore not
eligible to receive payment.
The Plan must follow Medicare rules. Medicare rules say that the provider is not enrolled in Medicare and
therefore not eligible to receive payment for service rendered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to
pay for the Home health aide or certified nurse assistant, providing care in the home; per hour (S9122 x 203)
provided from January 5, 2020, to January 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on November 11, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that you requested to go to a specific hospital but the ambulance service brought you somewhere else. You are unhappy with the service you received 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 a $325 copayment for ambulance services.

You have been asked to pay a $325 copayment for ambulance services. Ambulance services fall within the ambulance 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 copayment for ambulance services provided on November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewing x-rays, and prophylaxis provided on December 17, 2020 by an OON provider.

You asked the Plan to pay for the comprehensive oral evaluation, bitewing x-rays, and prophylaxis. You say that when you contacted the dental office you were advised that they were in-network with your plan. The Plan denied your request. The Plan says these services were performed by a non-participating provider. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the 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, you are responsible for a 50% coinsurance plus the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewing x-rays, and prophylaxis provided on December 17, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish provided on December 16, 2020.

You asked the Plan to pay for the topical application of fluoride varnish. You say that you were told that this service would be covered. The Plan denied your request. The Plan says this service is 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.

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 topical application of fluoride varnish provided on December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility visits provided from October 3, 2019, through January 18, 2020.
You asked the Plan to pay for the skilled nursing facility visits. You say that you do not have staff that work for the facility. You say that you do not know what service the physician is providing care for during the time of services, therefore you do not have a way to obtain prior authorization. The Plan denied your request. The Plan says the services are unauthorized, routine care and the services are available in-Plan.
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 skilled nursing facility visits provided from October 3, 2019, through January 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided December 30, 2019.
You asked the Plan to waive the copayment for the hospital services. You say that you are being billed a $250 copay for a surgery that was scheduled then cancelled. You did not know the surgery was going to be cancelled and waited 4 hours in pre-op and was finally told the doctor had an emergency. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.
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 $250 copayment per day for days 1-6 for Inpatient hospital care. You have been asked to pay $125 copayment for the hospital services. The hospital services fall within the Inpatient hospital care 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 inpatient hospital services provided December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a right L5 primary dorsal ramus block and S1-S3LB RFA.

You asked the Plan to pre-approve a right L5 primary dorsal ramus block and S1-S3 LB RFA. You say that the requested right L5 primary dorsal ramus block and S1-S3 LB RFA is medically necessary.The Plan denied your request. The Plan says the requested right L5 primary dorsal ramus block and S1-S3 LB RFA 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 right L5 primary dorsal ramus block and S1-S3 LB RFA. Our reviewer says that the requested right L5 primary dorsal ramus block and S1-S3 LB RFA is not medically necessary. Our physician reviewer found the enrollee has chronic SI joint pain. He had RFA of the lateral Sacral branches on 10/12/18 with 100% pain relief for more than 12 months. He currently takes Tramadol for pain. He had a diagnostic SI joint injection on 3/5/21 with 50% pain  relief. The request is for repeat RFA. This is considered an experimental/investigational procedure because of the wide variation in efficacy published in the peer reviewed 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 a right L5 primary dorsal ramus block and S1-S3 LB RFA have not been met.Therefore, we decided that the Plan does not have to pre-approve a right L5 primary dorsal ramus block and S1-S3 LB RFA.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99214) electrocardiogram, routine ECG with at least 12 leads (93000) provided December 31, 2020.

You asked the Plan to waive the copayment for the office visit and diagnostic service. You say that you received a bill showing that you owe $40 without an explanation why. You checked your bank and payment of $35 was taken out January 4, 2021. You are upset over this as you are receiving a bill without proper explanation. The Plan denied your request. The Plan says the claim was processed and the correct copayment was provided per the Evidence of Coverage.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $5 copayment for diagnostic lab services and diagnostic procedures and tests and $35 copayment for each specialist visit. 

You have been asked to pay $40 copayment for the office visit and diagnostic service. The office visit and diagnostic service falls within the Outpatient diagnostic tests and therapeutic services and supplies and Physician/Practitioner services, including doctor's office visits benefit categories. 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 office visit (99214) electrocardiogram, routine ECG with at least 12 leads (93000) provided December 31, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on June 25, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that the enrollee is being held responsible for two copayment amounts which is incorrect. You say that you were informed the code was minor diagnostic with a $50 copayment. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $150 copayment for each Medicare-covered radiological diagnostic service, not including X-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). The enrollee has been asked to pay a $150 copayment for the ultrasound. The ultrasound falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound provided on June 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Augmentin provided on February 10, 2021.

You asked the Plan to pay for Augmentin. You say that the emergency room does not stop to see what medication is covered. The Plan denied your request. The Plan says there is no coverage for self-administered drugs provided in an emergency room.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. Drugs taken in an outpatient setting, that are normally self-administered drugs, are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for Augmentin provided on February 10, 2021.

Benefits for Augmentin may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for neurophysiology services provided to the enrollee on August 9, 2020.

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 denied codes remain 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 the denied codes is:

CPT 95939: 

Central motor evoked potential study (transcranial motor stimulation)

CPT 95938: 

Short-latency somatosensory evoked potentials study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; upper and lower limbs

CPT 95861: 

Needle electromyography; two extremities, with or without related paraspinal areas

CPT 95865: 

Needle measurement and recording of electrical activity of muscles of voice box

CPT 95868: 

Needle electromyography; cranial nerve supplied muscles, bilateral

CPT 95927: 

Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system

We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found per the the Plan's guidelines: the Plan's Medicare Advantage Reimbursement Policy CMS 1500 Policy Number 2020R9041B "Services furnished in a mobile unit are often provided to serve an entity for which another POS code exists. When this is the case, the POS for that entity should be reported. the Plan's Medicare Advantage will only allow reimbursement for IONM services when reported with POS 19, 21, 22 and 24.'' Therefore, place of service 15 is not correct place of service to report.

We looked at this coder'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 pay for neurophysiology services provided to the enrollee on August 9, 2020.