Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit.

You asked the Plan to waive the copayment for the specialist office visit. You say that you are appealing this bill. You say you already paid it. The Plan denied your request. The Plan says you have been asked to pay 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 provider and professional services provided at an in-network specialist's office.

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. 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery to on the nose, septoplasty or submucous
resection (30520) excision inferior turbinate, partial or complete, any method (30130) tonsillectomy, primary
or secondary (42826).

You asked the Plan to pre-approve the surgical procedure. You say that all of the information needed is in the
notes. Please review records once more. The Plan denied your request. The Plan says the records provided does
not support that the enrollee meets the medically necessary criteria for the requested service.

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 surgical procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee's physical exam on 6 different office visits over 2 years states that the
enrollee has a normal septum. It is unclear how she was diagnosed with a deviated nasal septum. There is no
documentation stating the enrollee tried intranasal steroid spray to address the turbinate hypertrophy. The
enrollee should try medical management first before proceeding with surgery to reduce the turbinates. There is
no documentation that she suffers from recurrent tonsil infection, tonsil stones, tonsil abscess, peritonsillar
abscess or obstructive breathing secondary to tonsils. It is not clear why she was diagnosed with chronic
tonsillitis.

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 surgical procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve surgery to on the nose, septoplasty or submucous resection (30520) excision
inferior turbinate, partial or complete, any method (30130) tonsillectomy, primary or secondary (42826).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210).

You asked the Plan to pay for the dental service. You say that when the dental office ran your insurance card,
you were advised the services would be covered. You say that you cannot afford this bill. You also say that you
would not have had the service done if you knew it would not be covered. The Plan denied your request. The
Plan says complete series x-ray is not listed as 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 pay for the
complete series x-ray (D0210).
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 may require skilled physical therapy and occupational therapy but based on the medical records provided It is not clear you would be able to fully benefit and/or participate in an IRF level of care.

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 visual field assessment services identified with code 0379T.

You asked the Plan to pre-approve visual field assessment services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve visual field assessment services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the provided documentation includes a form letter signed by the ordering physician that describes the service and offers a conclusory statement that it is medically necessary. No enrollee specific medical records are provided to determine the medical reasonableness and necessity of the requested service. The elements of the coverage determination are not satisfied. Therefore, the enrollee does not meet criteria for the requested services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of visual field assessment services have not been met. Therefore, we decided that the Plan does not have to pre-approve visual field assessment services identified with code 0379T.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you believe that this service was incorrectly denied for coverage. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded. The Plan also says that you were not provided misinformation during your call with the 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, comprehensive oral evaluation is limited to one procedure every three years. The record shows that you received a comprehensive oral evaluation and your comprehensive oral evaluation benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-skilled home health care for assistance with activities of daily living.

You asked the Plan to pre-approve non-skilled home health care. You say that you cannot do things for yourself and that you need help in your home. The Plan denied your request. The Plan says rules for home health care have not been met.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-skilled home health care have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve non-skilled home health care for assistance with activities of daily living.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110) and the partial lower denture (D5212).

You asked the Plan to pay for the dental services. You say that you do not recollect that you received new dentures in the past 5 years. You also say that this procedure would not have been scheduled had you known it would be denied. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan says the frequency limit has 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 and dentures are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for the dentures you received on January Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) and the partial lower denture (D5212).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.

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 there are no identifiable skilled nursing
service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled
nursing or therapy services on a daily basis. This enrollee does 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 care have not
been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of torus mandibularis (D7473), the initial 15 minutes of intravenous (IV) conscious sedation (D9239), the additional 15 minutes of IV conscious sedation (D9243 x 4), and the therapeutic parenteral drug (D9610).

You asked the Plan to pay for the dental services. You say that you called the plan 3 times. You say that a plan representative advised which dental coverage you should get in order for oral surgery to be covered. You say that you were advised oral surgery was covered at 25% and anesthesia was covered at 50%. You also say that you feel that you were misled about this service being covered. The Plan denied your request. The Plan says the dental services you received are not listed as covered service. The Plan also says that you were advised that your plan covers oral surgery for extractions.

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 removal of torus mandibularis (D7473), the initial 15 minutes of intravenous (IV) conscious sedation (D9239), the additional 15 minutes of IV conscious sedation (D9243 x 4), and the therapeutic parenteral drug (D9610).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care discharge day management services
coded 99217 provided on October 17, 2020.

You asked the Plan to pay for the observation care 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 payable.

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 99217 is not supported in the medical record. Specifically, this code was already paid
for the same date of service by the same provider. Based on this information, we decided that Medicare rules
for coverage of the observation care discharge day management services have not been met. Therefore, we
decided that the Plan does not have to pay for the observation care discharge day management services coded
99217 provided on October 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of torus mandibularis (CPT code D7473), deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15 minute increment (D9223), therapeutic parenteral drug, single administration (D9610), and consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310).

You asked the Plan to pre-approve the dental services. You say that the bone shaving is done in order for bottom dentures to fit and the anesthesia is needed for the provider. You state you cannot afford to pay for this and can only eat soft foods and are in pain. The Plan denied your request. The Plan says the services are not a covered benefit under the 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. The services are not listed in your handbook as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pre-approve removal of torus mandibularis (CPT code D7473), deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15 minute increment (D9223), therapeutic parenteral drug, single administration (D9610), and consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6750 x 4), a pontic (D6240)), a root canal (D3310), and post and core in addition to a crown (D2952).

You asked the Plan to pre-approve the dental services. You say that you have several medical conditions. You say that you have $4,100 to go towards the dental services. You say that you will still owe $1,500 for your treatment. You also say that you would like some help with the dental work that you need. The Plan denied your request. The Plan says retainer crowns are not listed as covered services. The Plan says that pontic is not listed as a covered service. The Plan says that root canal is not listed as a covered service. The Plan also says that post and core in addition to a crown is not listed as a covered service 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. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6750 x 4), a pontic (D6240)), a root canal (D3310), and post and core in addition to a crown (D2952).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) genetic testing panel (81455).

You asked the Plan to pay for the F1Heme testing. You say that this testing was validated by the Centers for Medicare and Medicaid Service and cannot be denied by a Medicare Advantage plan. You provide reference to an LCD L38047 as evidence of coverage. The Plan denied your request. The Plan says there are numerous Medicare coverage rules which indicate that this type of panel must be billed with code 81479 along with the DEX Z-code. As such, this was incorrectly coded and cannot be paid.

Maximus reviewed the regulations cited by both the lab and the Plan. We find that these regulations do not apply either to the State in which this testing was performed or for the specific type of testing at issue. As such, our review is based on the regulations noted in the Medicare Rules section.

The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to support the medical necessity of Genomic Sequential Analyses panels for patients with CML for a limited number of individual biomarkers. Panels which test the covered biomarkers and are described by code 81450 may be covered by Medicare.

We looked at the file and Medicare rules. Review of the information in the file shows that this panel includes analysis of over 50 genes. The billed code 81455 is defined as targeted genomic sequencing with analysis for 51 or more genes. Although some of these genes may be considered medically necessary based on the rules, the entire panel exceeds what is covered under these provisions. Based on this information, we decided that Medicare rules for coverage of the F1Heme testing have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) genetic testing panel (81455).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for oral surgery.

You asked the Plan to pay for dental service. You say that this surgery was not cosmetic, and you would not have had this surgery if it were unnecessary. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this procedure was cosmetic which is not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover dental services that are cosmetic or aesthetic in nature. Medicare rules say that the provider, supplier, or beneficiary must furnish to the Plan sufficient information to determine whether payment is due for a claim.

We looked at the file and Medicare rules. No medical records were submitted to the Plan to support coverage for the billed service. The Plan made efforts to obtain medical records from the out-of-network provider, but none were submitted. The Plan says that this service was cosmetic in nature, which is not covered by the Plan's dental benefits. You say that this procedure was not cosmetic and was necessary for you. Without medical records, we cannot determine whether or not this oral surgery was cosmetic in nature. Therefore, it has not been shown that the billed service meets the Plan's criteria for coverage. Therefore, we decided that the Plan does not have to pay for oral surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, resin-based composite of one surface, resin-based composite of two surfaces, and re-cement or re-bond of a crown provided by an OON provider.

You asked the Plan to pay for the problem focused limited oral evaluation, resin-based composite, and re-cement or re-bond of a crown. You say that you were not aware that you did not have OON coverage. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, resin-based composite of one surface, resin-based composite of two surfaces, and re-cement or re-bond of a crown provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Zolpidem 10mg tablet medication (J8499).

You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the enrollee's contractual policy.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Zolpidem 10mg tablet medication (J8499).

Benefits for this medication may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.