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

We decided that the Plan does not have to pay forthe bone graft of tooth 30  (D7950) of tooth 30 provided October 31, 2019.You asked the Plan to pay forthe dental services. You say that your dentists told you that the plan denied because the procedure is limited to once per lifetime. You have never previously had this procedure on this tooth and you feel this should be covered.The Plandenied your request. The Plan says this service is not covered under the plan 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. The health plan contract says that bone grafting is covered as part of surgical procedure. This information can be found on page 109 of the plan's Evidence of Coverage.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 forthe bone graft of tooth 30  (D7950) of tooth 30 provided October 31, 2019
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forEmergency Room Services (99283) provided December 14, 2019.You asked the Plan to pay forthe Emergency Room Services. You say that the services were medically necessary.The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed by the same physician's group on the same date of service.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, we have confirmed that code the 99283 has a bundled relationship with code 99285, which was already processed, and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forEmergency Room Services (99283) provided December 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete dentures (D5110 and D5120). You asked the Plan to pre-approve complete dentures (D5110 and D5120). You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says you have exhausted this benefit for the 2020 benefit 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.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dentures are only provided once every five years. The file shows you received dentures on October 17, 2019, which is less than five years ago.Therefore, we decided that the Plan does not have to pre-approve complete dentures (D5110 and D5120). Your complaint about your current dentures is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for drug testing services (CPT 99213 and CPT 80305) provided to the
enrollee on December 2, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says that the documentation shows that an established patient received an outpatient visit and
underwent a urine drug screen. Therefore, the billing of CPT 99213 and CPT 80305 is 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 99213:
Evaluation and management of an established patient in an office or outpatient location for 15 minutes.
CPT 80305:
Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, (e.g.,
immunoassay) capable of being read by direct optical observation only (e.g., dipstick, cups, cards, cartridges)
includes sample validation when performed, per date of service (maps to 80300 or G0477).
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 services. Our reviewers says that the
services at issue in this case were not coded correctly. Our physician reviewer found the documentation shows
that an established patient received an outpatient visit and underwent a urine drug screen. Therefore, the billing
of CPT 99213 and CPT 80305 is supported.
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 been met. Therefore, we decided that the Plan has to pay for
drug testing services (CPT 99213 and CPT 80305) provided to the enrollee on December 2, 2019.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance services provided on April 27, 2019.
You asked the Plan to pay for the air ambulance services. You say that you pay premiums to be covered in such emergent situations. The Plan denied your request. The Plan says you were not transported to your home state not the nearest appropriate facility.
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 looked at the file and Medicare rules. You did not get prior approval and you were not transported to the nearest appropriate facility. Based on this information, we decided that Medicare rules for coverage of the air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance services provided on April 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from September 10, 2019 to September 13, 2019.You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges because the stay was within 60 days of a previous stay.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 $295 copayment each day for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from September 10, 2019 to September 13, 2019. Therefore, you are responsible to pay a $295 copayment for days 1-3 (September 10, 2019 to September 12, 2019). $295 (copayment) x 3 (inpatient days) = $885. You have been asked to pay the total copayment amount of $885 for an inpatient hospital stay. An inpatient hospital stay falls 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 an inpatient hospital stay provided from September 10, 2019 to September 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe consultation and extractions to be provided by an oral surgeon.You asked the Plan to pre-approvethe consultation and extractions. You say that your dentist referred you to an oral surgeon because you need to have 11 teeth removed. You also say that 6 teeth have gone bad and 3 teeth are broken at the gum line.The Plan denied your request. The Plan says consults and extractions provided by oral surgeons, periodontists, endodontists, other dental specialists, or non-network general dentists 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.Though the Plan offers a dental benefit inexcess of Medicare coverage, the requested items or services are not covered when they are received by any provider other than a participating general dentist.Therefore, we decided that the Plan does not have to pre-approvethe consultation and extractions to be provided by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone growth stimulator.You asked the Plan to pre-approve bone growth stimulator (E0760). You say that the enrollee has acute ankle pain and a bone growth stimulator would promote healing and help avoid surgery. The Plan denied your request. The Plan says the enrollee does not have a diagnosis of a bone fracture.The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days.In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not show a diagnosis of a fracture. Therefore, we decided that the Plan does not have to pre-approve a bone growth stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous electrical nerve stimulator.
You asked the Plan to pre-approve the requested device. You say that the device is needed to alleviate the enrollee's chronic pain and increase the enrollee's ability to participate in daily activities. The Plan denied your request. The Plan says auricular devices are non-covered as electrical acupuncture.
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 requested device. Our physician reviewer found that the enrollee has neck pain, upper and lower back pain, shoulder and knee pain. She has tried Yoga, Diclofenac, Gabapentin, Tramadol, Hydrocodone/Acetaminophen, and Flexeril. The request is for an auricular stimulator. This is an experimental/investigational device. This therapy is not evidence based and is not part of any established clinical practice guideline. Therefore, the requested device is 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 the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous electrical nerve stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Oximeter, non-invasive (E0445).

You asked the Plan to pre-approve the Oximeter. You say that it has been 8 days since your mother left the hospital and has not received her equipment. She has difficulty breathing and the doctor already sent the prescription twice. The Plan denied your request. The Plan says this service is not covered under Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say that Oximeters are not covered because they are monitoring devices that provide information to physicians to assist in managing the beneficiary's treatment.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Oximeter have not been met. Therefore, we decided that the Plan does not have to pre-approve the Oximeter, non-invasive (E0445).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says continued skilled therapy will not result in a significant and sustainable functional improvement.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.Continued SNF services beyond June 25, 2020, were requested. 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 physician reviewer found that from a nursing perspective, you had stable vital signs. You were treated for a skin tear to your sacrococcygeal area. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a minimal to moderate assist level with functional mobility. You require varying assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.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 continued skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the cervical spine.
You asked the Plan to pre-approve MRI. You say that you do not understand why this was denied by the Plan. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the Plan was unable to determine the medical necessity of this test.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that MRIs are covered only when they are medically necessary. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not submitted any medical records for review of your request. The Plan has also not provided documentation of any attempts to obtain medical records for review. Without this information, we cannot determine whether you meet the Medicare criteria for the requested MRI. Therefore, the Plan has not shown that its decision to deny coverage is medically justified or correct according to Medicare rules. Therefore, we decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the cervical spine.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomography (CT) Colonography (74263).
You asked the Plan to pre-approve the Colonography. You say that the Colonography is medically necessary. The Plan denied your request. The Plan says CT Colonography for screening purposes is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that Screening computed tomographic Colonography (CTC) is non-covered. We looked at the file and Medicare rules. The requested service is not a covered screening service under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Colonography have not been met. Therefore, we decided that the Plan does not have to pre-approve a Computed Tomography (CT) Colonography (74263).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to restore 2020 vision care benefits for eye wear.You asked the Plan to restore 2020 vision care benefits for eye wear. You say that the cost of $445 was unnecessary and you could have used that for the frames of other lenses. You hope for reimbursement because you need eyeglasses that will satisfy your necessity.The Plan denied your request. The Plan says the benefit has been exhausted.On February 20, 2020, the enrollee selected and placed the order for two eyeglasses. The two pairs of eyeglasses were prepared according to the prescription and specifications received and are ready to be picked up. The total of the two designer frames and prescribed lenses was $1,228. The plan applied the $1,200 eyewear benefit leaving the enrollee a balance of $28. The vision benefit has been exhausted and will not be available until 2021.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. The Plan covers an annual maximum of $1,200 for eye wear every year. We looked at your request, the records in the case file and the rules. Based on this information, we decided that the you have exhausted the Plan's maximum benefit for non-Medicare covered eyewear.Therefore, we decided that the Plan does not have to restore 2020 vision care benefits for eye wear. Your complaint about the service you received from the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF coverage under the Medicare Part A benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a brand specific Blood Pressure Machine Drive #BP3400. You asked the Plan to pre-approve the blood pressure machine . You say that the screen on the current blood pressure monitor is too small and you would like to return the current monitor, model# meds1001 and exchange it to model Drive BP 3400. The Plan denied your request. The Plan says this item is not a covered benefit. The request for a brand specific blood pressure machine is considered not medically reasonable and necessary. The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve a brand specific Blood Pressure Machine Drive #BP3400.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram provided on November 7, 2019.You asked the Plan to pay for the services provided. You say that the EKG results are in the emergency department notes.The Plan denied your request. The Plan says the claim was processed correctly.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 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. We find that CPT code 93010 is not separately payable. A professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram provided on November 7,
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from January 3, 2020 to January 28, 2020.You asked the Plan to pay for the skilled nursing services. You say that you should have had physical therapy after your hospital stay. You also say that this was recommended by the doctors and the denial put you at severe risk.The Plan denied your request. The Plan says you did not meet Medicare guidelines for services in a SNF.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the skilled nursing services. Our reviewer says that you did not meet the Medicare criteria for SNF care. Our physician reviewer found you did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. You did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. You did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from January 3, 2020 to January 28, 2020.