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

We decided that the Plan does not have to pay forthe periapical x-ray with dental code D0220 provided on July 29, 2020.You asked the Plan to pay fordental code D0220. 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.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 periapical x-ray with dental code D0220 is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe periapical x-ray with dental code D0220 provided on July 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvespine surgery.You asked the Plan to pre-approvespine surgery.You say that the enrollee needs theseproceduresfor pain relief.The Plan denied your request. The Plan says the enrollee is not in an approved clinical study.The Plan must follow Medicare rules. Medicare rules say thatenrollees must be enrolled in an approved clinical study.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spine surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvespine surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea spinal cord stimulator.You asked the Plan to pre-approvethe requested services. You say that the enrollee has tried more conservative methods, with no effective, long-term relief.The Plan denied your request. The Plan says the diagnostic indications required were not documented.The Plan must follow Medicare rules. Medicare rules say that spinal cord stimulation is only covered under certain medical indications. We looked at the file and Medicare rules. The documentation shows that the enrollee has a history of lumbar spondylosis, lumbar radiculopathy, anddisc degenerative disease. The records do not show the enrollee has a condition that is indicated for coverage. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met.Therefore, we decided that the Plan does not have to pre-approvea spinal cord stimulator.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approveMagnetic Resonance Imaging (MRI) of the arm joint.You asked the Plan to pre-approveMRI. You say that you need to know what the cause of your pain is which the X-Ray did not show.The Plan denied your request. The Plan says that the denial of authorization for this test is correct, because this MRI is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI. Our reviewer says that you meet the Medicare criteria for the requested MRI. Our physician reviewer found you have had several follow-up visits and several imaging studies that have been negative and not yielded diagnosis of the cause of your pain. MRI is medically reasonable and indicated due to the thorough nature of the work prior to this imaging study.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI have been met.Therefore, we decided that the Plan has to pre-approveMagnetic Resonance Imaging (MRI) of the arm joint.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 toopen the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray, preventive procedure, and periodontal maintenance provided on July 20, 2020.
You asked the Plan to pay for the additional intraoral periapical x-ray, preventive procedure, and periodontal maintenance. You say that you should not receive any dental bills because you have two dental insurance plans. The Plan denied your request. The Plan says your benefits for the additional intraoral periapical x-ray have been satisfied and the frequency limitation has been exceeded. The Plan says that you are responsible for a 70% coinsurance for periodontal maintenance. The Plan also says that participating providers are receiving a separate monthly stipend for the unspecified preventive procedure with no additional payments being made.
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, intraoral x-rays and are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on July 20, 2020, and your intraoral x-rays benefit has been exhausted. Periodontal maintenance is also listed as a covered benefit, and you are responsible for a 70% coinsurance. Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray, preventive procedure, and periodontal maintenance provided on July 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says there is no prior authorization for the services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 laboratory 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 laboratory services provided.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora sleep study provided to the enrollee on May 26, 2020.You asked the Planto pay forthe study. You say that this should be paid for.The Plandenied your request. The Plansaysprior authorization is required for all non-contracted providers.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 careand pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 Plandoes not haveto pay fora sleep study provided to the enrollee on May 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecrown -full cast high noble metal (D2790).You asked the Plan to pre-approvea crown. You say that the service is medically necessary.The Plan denied your request. The Plan says the x rays provided did not show any evidence of a broken tooth or any missing part due to cavities. The tooth does not appear to have significant breakdown due to decay or trauma.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 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 crown. Our reviewer says that the service is not medically necessary. Our physician reviewer found that, tooth #18 does not appear to have significant coronal breakdown due to cavities or fracture to warrant a crown restoration.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 crown have not been met.Therefore, we decided that the Plan does not have to pre-approvecrown -full cast high noble metal (D2790).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical placement of implants and related services performed on March 19, 2019, to February 5, 2020.You asked the Plan to pay forthe surgical placement of implants and related services. You say that these services should be covered.The Plan denied your request. The Plan says rules for payment have not been met.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.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 surgical placement of implants and related services performed on March 19, 2019, to February 5, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRFadmission and services.You asked the Plan to pre-approve IRF care. You say that the enrollee currently meets the CMS guidelines for an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for admission to acute inpatient rehabilitation.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that based on the documentation provided, the health Plan's denial should be upheld.The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe self-administered drugs provided from July 15, 2020 to July 17, 2020.You asked the Plan to pay forthe self-administered drugs. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the self-administered drugs you received are not covered under your Medicare Part B benefit.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 pay forthe self-administered drugs provided from July 15, 2020 to July 17, 2020.Benefits for the self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe extremity venous duplex scan (93970) services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe extremity venous duplex scan (93970) services to be provided by an OON provider. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available to you that can provide the duplex scan you are requesting.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Planhas to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe extremity venous duplex scan (93970) services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need IRF care as you have been making progress
and will benefit greatly from more intense therapy. The Plan denied your request. The Plan says based on the
clinical information received, you do not meet the guidelines for IRF services as the clinical information
indicates that your needs can be safely met in a skilled nursing facility setting, if ordered by your doctor.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found based on the medical records provided the complexity of your nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. You do not require an intensive inpatient rehabilitation therapy program. There is no
documentation that you require the intensive rehabilitation therapy program provided in an inpatient
rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe surgical procedure for isolation of tooth (D3910), bone replacement graft (D7953), unspecified preventative procedure (D1999), and guided tissue regeneration (D4266).You asked the Plan to pre-approvethe surgical procedures for isolation of tooth, bone replacement graft, unspecified preventative procedure, and guided tissue regeneration. You say that these services are medically necessary for your condition.The Plan denied your request. The Plan says these services are not covered under the member's benefit package.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 ofMedicare 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-approvethe surgical procedure for isolation of tooth (D3910), bone replacement graft (D7953), unspecified preventative procedure (D1999), and guided tissue regeneration (D4266)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBudesonide-formoterol.You asked the Plan to pre-approveBudesonide-formoterol. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Budesonide-formoterol is not covered under the enrollee's Medicare Part B benefit.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-approveBudesonide-formoterol.Benefits for Budesonide-formoterolmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOxycontin.You asked the Plan to pre-approveOxycontin. The Plan denied your request. The Plan says your medical plan does not cover outpatient prescription drugs.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 requestedhere are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveOxycontin.Benefits for Oxycontinmay be available under Medicare Part D.Contactthe 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 pre-approve2 apicoectomy (D3425) and 4 retrograde fillings (D3430).You asked the Plan to pre-approvethe apicoectomies and retrograde fillings. You say that you have been waiting months to get crowns. You say that your teeth have been ground down to nubs. You say that chewing is difficult and painful. You also say that you have no molars on the right side.The Plan denied your request. The Plan says apicoectomy is not listed as a covered service. The Plan says that retrograde fillings are not listed as covered services either.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. The Evidence of Coverage clearly states that any services not listed are not covered.Therefore, we decided that the Plan does not have to pre-approve2 apicoectomy (D3425) and 4 retrograde fillings (D3430).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
You asked the Plan to pre-approve the mandibular partial denture. You say that you received dentures in 2017, but they never fit right. The Plan denied your request. The Plan says you have received a full or partial denture within the last 96 months, and your frequency limit has been met.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, mandibular partial denture (D5214) is covered once every 96 months. The record shows that you received a mandibular partial denture in 2017, and your mandibular partial denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing with CPT code 95999 provided on February 12, 2020.
You asked the Plan to pay for CPT code 95999. 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 providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95999 is Unlisted neurological or neuromuscular diagnostic procedure. We find that CPT code 95999 is not supported in the medical record. Specifically, the record shows that train of four testing was performed and this is not the appropriate code for this service. Per Medicare guidelines, it is inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. There is no separate code for train of four monitoring. Based on this information, we decided that Medicare rules for coverage of CPT code 95999 have not been met. Therefore, we decided that the Plan does not have to pay for the train of four testing with CPT code 95999 provided on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hospital discharge day management services coded 99239 provided on March 30, 2020.You asked the Plan to pay forthe hospital discharge day management services. 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. 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 99239 is hospital discharge day management; more than 30 minutes.We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of a hospital discharge daymanagement note of 30 minutes or more for the billed date of service; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met.Therefore, we decided that the Plan does not have to pay forthe hospital discharge day management services coded 99239 provided on March 30, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup (D2950).
You asked the Plan to pre-approve the core buildup. You say that the services requested are medically necessary. The Plan denied your request. The Plan says this is not a covered service.
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 the core buildup (D2950).