Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the abutment supported crown. We decided that the Plan does not have to pay for the custom fabricated abutment.
You asked the Plan to pay for the abutment supported crown. You say that you had a tooth extracted and an implant placed in 2019. You say that you had an abutment and crown placed on tooth # 30. You say that the Evidence of Coverage states "crowns placed over implants will be covered." You also say that you expect coverage at the out of network rate. The Plan denied your request. The Plan says that implant services are not covered. The Plan also says that x-rays are being submitted for review.
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 dental service when the services are medically necessary and reasonable.
We decided that the Plan has to pay for the abutment supported crown.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the dental service. Our reviewer says that the abutment supported crown is medically necessary. Our physician reviewer found the provided documentation shows a well-integrated implant body ready to be restored. The reviewer found that the crown to be placed after abutment placement would be a covered service as it is specifically provided for. The reviewer found that given the plan language provided in the EOC the crown would be a covered service. Though the Plan offers a dental benefit in excess of Medicare coverage, the custom fabricated abutment is not among those covered under this benefit. Therefore, we decided that the Plan has to pay for the abutment supported crown.
We also decided that the Plan does not have to pay for the custom fabricated abutment.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the dental service. Our reviewer says that the custom fabricated abutment is not medically necessary. The reviewer found that the abutment would not be a covered service, per the plan documents.
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 custom fabricated abutment have not been met. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0120), bitewing x-rays (D0274), and dental cleaning (D1110).

You asked the Plan to pay for the dental services. You say that you were referred to this provider by your health plan and believed they were in network. The Plan denied your request. The Plan says this denial is upheld because this provider is out-of-network and the Plan does not cover out-of-network care. However, the Plan also stated in their Reconsideration decision, that they will not be charging you despite the denial. The office has written off the claim due to using an out-of-network provider in error.

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, out-of-network items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral evaluation (D0120), bitewing x-rays (D0274), and dental cleaning (D1110).

Your complaint about misinformation regarding the network status of a 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. Please note that it appears that the Plan has already researched and addressed your concern, and the record indicates that after the grievance review the Plan has decided that you will not be held responsible for the cost of these services. They have contacted the office and verified that you will not be charged for these services, and the office has written off the claim due to the error.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) nerve ablation.

You asked the Plan to pre-approve SI nerve ablation. You say that you have consistent pain and steroid shots do not have a positive effect on your pain management. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this is considered experimental/investigational.

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 SI nerve ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental/investigational because of the wide variation in efficacy reported. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SI nerve ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac (SI) nerve ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dispensing fee, monaural hearing aid, any type (CPT code
V5241).

You asked the Plan to pay for the services. You say that you have been through a lot just to get the hearing aid
so you can hear properly, and you are hoping that it could be covered. The Plan denied your request. The Plan
says the fitting and adjustment of hearing aids is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related
services.

Though the services may be appropriate in this case, neither Medicare nor the Plan covers or pays for these
types of items and services. Therefore, we decided that the Plan does not have to pay for dispensing fee,
monaural hearing aid, any type (CPT code V5241).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341), gingival irrigation (D4921), and drugs dispensed in the office for home use (D9630), provided on October 6, 2020.
You asked the Plan to pay for the deep-cleaning dental services. You say that you had an appointment to get a crown put in, but your dental provider advised that a deep cleaning was necessary to prevent a potential infection later. The Plan denied your request. The Plan says the provided services are not covered by Medicare or by the Plan's supplemental dental benefit. You are only participating in the Plan's mandatory benefit, which includes specific routine preventative services.
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 periodontal scaling and root planing (D4341), gingival irrigation (D4921), and drugs dispensed in the office for home use (D9630), provided on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy (97802).

You asked the Plan to pay for medical nutrition therapy. You say that this denied incorrectly. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that medical nutrition therapy services are covered for certain beneficiaries who have diabetes or a renal disease.

We looked at the file and Medicare rules. The enrollee does not have diabetes or renal disease. Based on this information, we decided that Medicare rules for coverage of medical nutrition therapy have not been met. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy (97802).

Your complaint about this claim not being processed as enrollee responsibility 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 8, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease
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 pay for the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a fifty year old woman with hypertension, hypercholesterolemia, and dysrhythmia history. Cardiac genetic screening of 117 genes had been requested. In this case, the file does not contain medical records sufficient enough to determine the medical reasonableness or necessity of the requested services. Therefore, the requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health services provided to the enrollee on September 28, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there was no authorization, and needs could be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of September 30, 2020 forward as the enrollee was not shown to be a danger to herself or others. The enrollee was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. The enrollee was not showing any aggressive behaviors. There was no treatment required for acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question. The health plan's denial of continued inpatient psychiatric services is appropriate. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient mental health services provided to the enrollee on September 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lab services you received on December 4, 2020.
You asked the Plan to waive the copayment. You say that you did not have lab services. The Plan denied your request. The Plan says you are responsible for the copayment.
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 $5 copayment per provider per day for Medicare-covered lab services. Review of the file shows that you were provided lab services on December 4, 2020. You have been asked to pay a $5 copayment for the lab services. The services fall within the outpatient diagnostic tests 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 lab services you received on December 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the member would benefit from additional therapy sessions. The Plan denied your request. The Plan says that the enrollee may be equally well served at an alternative level of care.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan.

You asked the Plan to waive the copayment for the CT scan. You say that it is not fair that you have a $195 copayment and insurance only paid $10. The Plan denied your request. The Plan says the copayment applied 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 $195 copayment for all other diagnostic and nuclear medicine radiological services.

You have been asked to pay a $195 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 CT scan.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pathology services coded 81291, 81225, 81227, 81226, 81240, 81241, 81328, 81355, 81401, 81479, 81335, 81408, 81400, 81230, 81231, 81232, 81256, 81283, 81406, and 81350.

You asked the Plan to pay for the molecular pathology services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

Review of the file shows that the plan uses Local Coverage Article (LCA) A57880 to support their denial. However, this LCA is not valid for the provider's billing state of Texas. Therefore, we are unable to use LCA A57880 to substantiate our decision.

We find that CPT codes 81291, 81225, 81227, 81226, 81240, 81241, 81328, 81355, 81401, 81479, 81335, 81408, 81400, 81230, 81231, 81232, 81256, 81283, 81406, and 81350 are not supported in the medical record. Specifically, coverage when a laboratory assays two or more genes in a patient in parallel are non-covered. Those two or more genes will be considered part of the same panel. Based on this information, we decided that Medicare rules for coverage of the molecular pathology services have not been met. Therefore, we decided that the Plan does not have to pay for the molecular pathology services coded 81291, 81225, 81227, 81226, 81240, 81241, 81328, 81355, 81401, 81479, 81335, 81408, 81400, 81230, 81231, 81232, 81256, 81283, 81406, and 81350.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 14, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the item provided was medically necessary for the enrollee. The Plan denied your request. The Plan says there are no medical records that support that the prescribing physician saw the member.
The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is subject to the coverage criteria listed 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 pay for the lumbar-sacral orthosis. Our reviewer says that the item was not medically reasonable and necessary for the enrollee. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met.
The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation and a credible physical examination of the back. 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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the trastuzumab injection coded J9355 provided on July 31, 2020.
You asked the Plan to pay for the trastuzumab injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered 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 J9355 is injection, trastuzumab, excludes biosimilar, 10 mg. We find that CPT code J9355 is not supported in the medical record. Specifically, two units of this code were billed. The submitted medical records do not support the units billed. The documentation shows that 43 units were given, however, they do not identify the amount of drug wasted to support the additional units billed. Based on this information, we decided that Medicare rules for coverage of the trastuzumab injection have not been met. Therefore, we decided that the Plan does not have to pay for the trastuzumab injection coded J9355 provided on July 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist office visit provided on September 30, 2020, by
an OON provider.
You asked the Plan to pay for a specialist office visit. You say that you would like this claim reprocessed and
paid. You say that these services were referred to you by the member's gastroenterologist. The Plan denied your
request. The Plan says these services were not referred by a participating provider. The Plan says that these
services can be provided in-network.
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 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 a specialist office visit provided on September 30,
2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup procedures including any pins when required (D2950), to be provided for tooth 3 and tooth 23.

You asked the Plan to pre-approve the core buildup procedures. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental benefit.

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 procedures including any pins when required (D2950), to be provided for tooth 3 and tooth 23.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM).

You asked the Plan to pre-approve a Dexcom CGM. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM).