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

 
We decided that the Plan does not have to pay for the laboratory services provided on September 17, 2019. 
 
You asked the Plan to pay for the laboratory 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 payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all CYP panels should be billed with 81479 and 
are non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided on September 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown (D2740) for tooth #28. 
 
You asked the Plan to pre-approve the crown (D2740). The Plan denied your request. The Plan says the service 
is allowed once every 5 years. 
 
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 Plan also has a maximum benefit 
of one crown per tooth every 60 months. The Plan paid for a crown for tooth #28 provided on May 27, 2019, 
which exhausted the benefit. Therefore, we decided that the Plan does not have to pre-approve the crown 
(D2740) for tooth #28.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty, extra wide hospital bed (E0301).
You asked the Plan to pre-approve the hospital bed. You say that you would like reconsideration because you need a bigger bed to be able to move around and prevent bed sores, blood clots and infections. The Plan denied your request. The Plan says there is no indication in the medical records received that you weigh more than 350lbs.
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hospital bed have not been met. Specifically, the record does not indicate that you weigh more than 350lbs. Therefore, we decided that the Plan does not have to pre-approve a heavy duty, extra wide hospital bed (E0301).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 power operated vehicle.
You asked the Plan to pre-approve a Group 1 power operated vehicle. You say that the enrollee needs a Group 1 power operated vehicle. The Plan denied your request. The Plan says there is no information showing that the enrollee can operate the tiller steering system or that the home provides adequate access for operating the POV.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file does not show the enrollee can safely operate the PMD being requested in their home. There is no Home Assessment documentation. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 power operated vehicle.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on March 24, 2020.
You asked the Plan to waive the copay for the ambulance transport. You say that you were not notified of the copay prior to receiving the ambulance services. The Plan denied your request. The Plan says that the claim processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copay for each Medicare-covered one-way trip via ground ambulance. You have been asked to pay a $247.79 copay for the ambulance transport. The ambulance transport falls within the Medicare-covered one-way trip via ground ambulance benefit category. This means that you have been asked to pay less than the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the ambulance transport provided on March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 17, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the rest home visit (99336). You say that you would like reconsideration because 
the services rendered were medically necessary. The Plan denied your request. The Plan says prior 
authorization was not obtained as required under the plan benefits. 
 
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 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 Plan does not have to pay for the medical services provided on April 17, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image 
(D0230 x 2) and occlusal adjustment - limited, tooth #5 and  #29 (D9951 x 2) from March 23, 2020 through 
April 6, 2020 by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you were instructed the provider was in-
network. The Plan denied your request. The Plan says the claims were processed accordingly with your 2019 
EOC 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. 
 
Review of the your records show that you saw the dentist and received 3 sets of intraoral x-rays and 2 bite 
adjustment procedures at your dental visits. The Plan has already approved payment for one set of intraoral x-
rays. Therefore, the two (2) sets of intraoral - periapical each additional radiographic image (D0230 x 2) are 
your responsibility. Furthermore, occlusal adjustment - limited, tooth #5 and #29 (D9951 x 2) is not a covered 
benefit. Therefore, we decided that the Plan does not have to pay for intraoral - periapical each additional 
radiographic image (D0230 x 2) and occlusal adjustment - limited, tooth #5 and  #29 (D9951 x 2) from March 
23, 2020 through April 6, 2020 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on
September 18, 2019.
You asked the Plan to pay for genetic testing. You say that the treating physician ordered this testing as a
medically necessary and valuable tool when determining treatment for the enrollee. The Plan denied your
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with
the appropriate coding.
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479
for date of service September 18, 2019.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for
comprehensive genomic profile (CGP) testing provided on September 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a stay at an inpatient rehabilitation facility 
between February 17 and February 23, 2020. 
 
You asked the Plan to waive the copayment for a stay at an inpatient rehabilitation facility. You say that, 
following an inpatient surgical procedure, you did not leave the hospital but were only transferred to a different 
floor. 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). Inpatient rehabilitation is a distinct service from inpatient care. 
Your contract with the Plan clearly says that you must pay a $250 copayment per admission for inpatient 
hospital care services.  
 
You have been asked to pay a $250 copayment for a stay at an inpatient rehabilitation facility. A stay at an 
inpatient rehabilitation facility 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 a stay at an inpatient rehabilitation facility between February 17 and 
February 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on December 31, 2019 through February 1, 2020.
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because there was no indication that this was a Medicare Plan. The Plan denied your request. The Plan says this provider is not a certified Medicare approved facility.
The Plan must follow Medicare rules. Medicare rules say that Substance Abuse Facilities frequently attempt to enroll in Medicare, but are not eligible to do so. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. The billing provider is a Substance Abuse Facility and not eligible to enroll in Medicare. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided on December 31, 2019 through February 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
February 11, 2020. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this service was not 
cosmetic or a luxury service. You say you received a referral and should not have any responsibility. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing 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 $45 
copayment for physician specialist services.  
 
You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner services, including doctor's office visits benefit category. The medical 
record shows you were seen for further evaluation and management. 
 
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 specialist office visit provided on February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for sixteen (16) dental extractions (D7140 x 16), interim complete denture (maxillary) (D5810) and interim complete denture (mandibular) (D5811) provided to the enrollee on June 20, 2019.
You asked the Plan to pay for the dental services. You say that the removal of the enrollee's teeth is medically necessary. The Plan denied your request. The Plan says the enrollee you exhausted their benefit for dental extractions and the dentures 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. Review of the records show that the enrollee saw the dentist and received eighteen (18) dental extractions and upper and lower interim dentures, due to tooth decay causing the teeth to be non-restorable. Two (2) dental extractions have already been approved by the Plan, therefore, the enrollee is responsible for the 16 dental extractions. Furthermore, interim complete denture (maxillary) (D5810) and interim complete denture (mandibular)(D5811) are not listed as covered benefits. Therefore, we decided that the Plan does not have to pay for sixteen (16) dental extractions (D7140 x 16), interim complete denture (maxillary) (D5810) and interim complete denture (mandibular) (D5811) provided to the enrollee on June 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 19, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot
be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. 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 the drug testing services provided on December 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF 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 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 you were medically stable with debility with no evidence of need for supervision by a physical, medicine, and rehabilitation (PMR) Physician or needs acute rehab nursing care. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program. IRF admission is not medically necessary based on your current functional status and lack of medical complexity. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq injections.
You asked the Plan to pre-approve the Tecentriq. You say that you would like reconsideration because this
drug is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that
this drug is helpful for treatment of the member's condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 the Tecentriq. Our reviewer says that
the documentation does not support that Tecentriq is medically reasonable and necessary for the member. Our
physician reviewer found there is no compendia basis or literature to support this drug for the member's
condition.
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 Tecentriq have not been met. Therefore, we decided that the Plan does not
have to pre-approve Tecentriq injections.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Hyberbaric Oxygen Therapy.
You asked the Plan to pre-approve the Hyberbaric Oxygen Therapy. You say that you would like
reconsideration because this is the member's only remaining non-surgical option. The Plan denied your request.
The Plan says that the member's conditions are not listed as covered by Medicare.
The Plan follows Medicare rules. Medicare rules say that medically necessary services are those that are
reasonable and necessary for the diagnosis or treatment of an illness or injury.
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 Hyberbaric Oxygen Therapy. Our
reviewer says that Hyperbaric Oxygen has been used to treat cystitis successfully. The member has no other
options other than surgery and surgery poses morbidity, mortality and quality of life consequences. Our
physician reviewer found Hyperbaric Oxygen Therapy is medically reasonable, necessary and indicated given
the multiple consultations, failed conventional therapies and the implications of surgery.
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 Hyberbaric Oxygen Therapy have been met. Therefore, we decided that the
Plan has to pre-approve Hyberbaric Oxygen Therapy.
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: Surgery
Decision: Favorable

We decided that the Plan has to pay for a cystourethroscopy (52332) provided on March 20, 2019.
You asked the Plan to pay for a cystourethroscopy. You say that this code is supported. The Plan denied your request. The Plan says that this code is not documented in the operative report.
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 52332 is cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type). 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 a cystourethroscopy. Our reviewers says that this code is supported by the records. Our physician reviewer found the documentation shows that a cystourethroscopy was performed and a stent was placed as described by this code. 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 cystourethroscopy have been met. Therefore, we decided that the Plan has to pay for a cystourethroscopy (52332) provided on March 20, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses (V2781) purchased February 19, 2020.
You asked the Plan to pay for the vision services. You say that you have always ordered progressive lenses. You ordered 2 pairs of glasses and paid $330 for one and $375 for the other. Another $160 does not fit into your monthly budget plan. The Plan denied your request. The Plan says progressive lenses is not covered under the plan benefits.
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 1 pair of eyeglasses after each cataract surgery.
We looked at the file and the Plan's rules. Progressive lenses are not covered under the plan benefits. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781) purchased February 19, 2020.