Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on December 18, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services rendered on December 18, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90791) provided October 7, 2020 to January 4, 2021.

You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the allow amount.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code 90791 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90791) provided October 7, 2020 to January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2750) for tooth #18.
You asked the Plan to pre-approve the crown. You say that tooth #18 has secondary buccal decay. The Plan denied your request. The Plan says that this request is not 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 (D2750) for tooth #18 meets coverage criteria. Our physician reviewer found the enrollee's dental record and radiograph indicates the presence of a completed root canal and large restoration or crown on tooth #18 with recurrent caries. Our reviewer also found that a crown restoration (D2750) is medically necessary and reasonable to restore tooth #18 to adequate masticatory 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 pre-approve a crown (D2750) for tooth #18.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intermittent limb compression device (E0651).

You asked the Plan to pre-approve intermittent limb compression device. You say that this device is medically
necessary. The Plan denied your request. The Plan says the documentation has not proven that the enrollee has
failed a four-week trial of conservative therapies.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with
venous stasis ulcers.

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 intermittent limb compression device.
Our reviewer says that the requested device is not medically necessary and reasonable. Our physician reviewer
found that the documentation does not reveal a four-week trial of conservative therapy demonstrating failed
response to treatment has been completed. The four-week trial of conservative therapy must include regular
and compliant use of an appropriate compression bandage system or compression garment to provide adequate
graduated compression. The conservative treatment should include regular exercise and leg elevation. The
documentation does not reveal that this conservative therapy has been completed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of intermittent limb compression device have not been met. Therefore, we decided
that the Plan does not have to pre-approve the intermittent limb compression device (E0651).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (S9328) provided August 17, 2020.
You asked the Plan to pay for the home infusion services. You say that the service was medically necessary. The Plan denied your request. The Plan says this CPT code is not eligible payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S9328 is not supported in the medical record. Specifically, per the 2020 National Physician Fee Schedule, this code is marked with a status indicator of "I" which means it is not eligible for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion services (S9328) provided August 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injections (J9035) provided August 17, 2020.
You asked the Plan to waive the coinsurance for the injections. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 Part B drugs. You have been asked to pay a 20% coinsurance for the injections. The injections fall within the Part B drugs 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 injections (J9035) provided August 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency transportation.
You asked the Plan to pre-approve non-emergency transportation. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when if it is documented that your condition is such that other means of transportation could endanger your health and that transportation by ambulance is medically required. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergency transportation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307, G0480) provided on January 21, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not emergent or pre-authorized.
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 service 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 lab services (80307, G0480) provided on January 21, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the enrollee would benefit from inpatient therapy
with continued monitoring of her condition. The Plan denied your request. The Plan says the denial of
authorization for SNF care is correct.
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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on
an inpatient basis in a Skilled Nursing Facility (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 care have not been met. Therefore, we decided that the Plan does not have
to pre-approve Skilled Nursing Facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a
participating ambulatory center on January 29, 2021.

You asked the Plan to waive the copayment for an outpatient surgery. You say that you were told you would
not have a copayment. You say that it is not fair you were given incorrect information. The Plan denied your
request. The Plan says the correct copayment has been applied.

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 $200
copayment for outpatient surgery/ambulatory facility.

You have been asked to pay a $200 copayment for an outpatient surgery. The correct copayment has been
applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/ambulatory
facility 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 outpatient surgery provided
by a participating ambulatory center on January 29, 2021.

We note your complaint about being told you would not owe anything. Your complaint is a grievance that must
be answered by the health plan. Medicare does not permit us to make a decision about these types of
complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found at the time of admission, you were not expected to require hospitalization that would likely cross 2 midnights due to the quick resolution of symptoms and low severity and complexity of the case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a periodontal scaling and root planing of four or more teeth per quadrant (D4341) for the upper left quadrant.
You asked the Plan to pre-approve the scaling and planing. The Plan denied your request. The Plan says there are not four or more teeth present in the upper left quadrant.
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 scaling and planing 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 scaling and planing. Our reviewer says that the criteria for periodontal scaling and root planing of four or more teeth per quadrant (D4341) has not been met and there is no necessity for the procedure. Our physician reviewer found the only teeth present in the upper left quadrant are tooth #'s 9, 10 and 11. Our reviewer found that it is inappropriate to use code D4341 in situations where there are less than four involved teeth. Our physician reviewer also found that in this situation there are only three teeth in the upper left quadrant, and therefore the requested code would never be appropriately used.
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 scaling and planing have not been met. Therefore, we decided that the Plan does not have to pre-approve a periodontal scaling and root planing of four or more teeth per quadrant (D4341) for the upper left quadrant.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient physical therapy services provided October 21, 2020 to October 28, 2020.
You asked the Plan to waive the copayment for the outpatient physical therapy services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 copayment for each physical therapy visit. You have been asked to pay a $140 copayment for 4 outpatient therapy visits. 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 outpatient physical therapy services provided October 21, 2020 to October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), bitewings - four radiographic images (D0274) and limited oral evaluation - problem focused (D0140) provided March 13, 2020.
You asked the Plan to pay for the intraoral x-rays, bitewing x-rays and limited oral evaluation. You say that you were not told the dentist was out-of-network The Plan denied your request. The Plan says the dentist is not part of the Plan's network and therefore the services 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 the intraoral x-rays, bitewing x-rays and limited oral evaluation when you have selected and been assigned to a contracted dental office to provide and manage your dental services. We looked at the file and Medicare rules. The services at issue were provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the intraoral x-rays, bitewing x-rays and limited oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), bitewings - four radiographic images (D0274) and limited oral evaluation - problem focused (D0140) provided March 13, 2020.
Your complaint about not being aware that the dental office is not a contracted 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla.

You asked the Plan to pre-approve Otezla. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Otezla.

Benefits for Otezla 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure provided on December 3, 2020.
You asked the Plan to pay for the preventive procedure. You say that you would like to appeal this service. The Plan denied your request. The Plan says there is no coverage for this service under your 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 pay for the preventive procedure provided on December 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (86077) provided October 30, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the allowed amount.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 86077 is 1. You billed 3 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (86077) provided October 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and first
intraoral periapical x-ray provided on December 22, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray.
You say that you believe this service should be covered. The Plan denied your request. The Plan says the
problem focused limited oral evaluation is not a covered benefit. The Plan also says that your benefits for the
first intraoral periapical x-ray had been satisfied and the frequency limitation had been exceeded.
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, problem focused limited oral
evaluation is not among those covered under this benefit. The contract says that intraoral x-rays are limited to
one procedure per calendar year. The record shows that you received a first intraoral x-ray on November 10,
2020, and your intraoral x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have
to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on
December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99214) provided December 17, 2020.
You asked the Plan to waive the copayment for the office visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct amount was applied.
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 specialist visits. You have been asked to pay the allowable amount of $35.18 for the office visit. the office visit falls within the specialist visits 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 office visit (99214) provided December 17, 2020.