Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the CT scan services with CPT code 70450 provided on June 23, 2020.
You asked the Plan to pay for CPT code 70450. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan denied payment for CPT code 70450-26-XS provided on June 23, 2020, stating per the claims research either the modifier 25 does not support the Evaluation and Management code as significant, separately identifiable E/M service warranting separate reimbursement, or the modifiers 59, XE, XP, XS, or XU, does not recognize the procedural service as supported by the diagnoses submitted. However, the Plan has not provided any supporting documentation that this service cannot be paid as billed. Therefore, we decided that the Plan has to pay for the CT scan services with CPT code 70450 provided on June 23, 2020.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zoledronic acid injection (J3489), intravenous infusion (96365), laboratory service (80048), and the saline solution infusion (J7050) rendered by the out of network (OON) provider on August 14, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the Zoledronic acid injection (J3489), intravenous infusion (96365), laboratory service (80048), and the saline solution infusion (J7050) rendered by the out of network (OON) provider on August 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on July 22, 2020.
You asked the Plan to pay for the testing services. You say that the tests were provided in good faith. The Plan
denied your request. The Plan says there are no concerning symptoms or signs of misuse.
The Plan must follow Medicare rules. Medicare rules say that urine drug testing should be individualized based
on clinical history and risk assessment, and must be documented in the medical record.
We find that the testing at issue is not supported in the medical record. The records do not show that the testing
was ordered due to medication side effects or inefficacy, suspicious behaviors, self-escalation of dose, doctorshopping, indications/symptoms of illegal drug use, evidence of diversion, or other clinician documented
change in affect or behavioral pattern. Based on this information, we decided that Medicare rules for coverage
of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug
testing services provided on July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentfor the computed tomography (CT) scan of the abdomen and pelvis(74176) provided on June 15, 2020.You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.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 $325 copayment per day for Medicare-covered diagnostic radiology services. You have been asked to pay $273.14 for the Medicare-covered diagnostic radiology service provided. This amount is the Plan allowed amount which is less than the applicable copayment. 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 copaymentfor the computed tomography (CT) scan of the abdomen and pelvis (74176) provided on June 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea core buildup for tooth #30 (D2950).You asked the Planto pre-approvethe dental services. You say that this should be covered.The Plandenied your request. The Plansaysthis is not a covered 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 Plandoes not haveto pre-approvea core buildup for tooth #30 (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional accessories for a power wheelchair (E2377, E2300, E2313, E2311, K0108) for the enrollee.You asked the Plan to pre-approvethe services. You say that this is medically necessary.The Plan denied your request. The Plan says this is 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 the services. Our reviewer says that the requested additional accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found E2300 is statutorily non-covered. E2311 is non-covered if itssole function is to operate E2300. E2377 and E2313 are non-covered as the enrollee has adequate strength and coordination of the upper extremities (3/5 upper extremity strength documented in 09/15/2020 office visit note) to control the power options using their own switches. K0108 elbow blocks are not allowed as the wheelchair seat and back cushion codes are all-inclusive and included in E2610.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 pre-approveadditional accessories for a power wheelchair (E2377, E2300, E2313, E2311, K0108) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite fillings on anterior teeth rendered
on October 6, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the 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 requested items or services are not
among those covered under this benefit. The services at issue were resin-based composite fillings to teeth 4 and
5, which are not covered by the Plan. Therefore, we decided that the Plan does not have to pay for the resin-based
composite fillings on anterior teeth rendered on October 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that an acute inpatient rehabilitation facility admission is medically necessaryfor the member.The Plan denied your request. The Plan says the member does not meet criteria for coverage of an acute inpatient rehabilitation facility admission.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 consideredmedically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that in this case, the complexity of the member's nursing, medical and rehabilitation needs do not require an acute rehabilitationhospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, inan intensive rehabilitation therapy program. There is not a reasonable expectation that this member will be able to fully participate in and benefit from anintensive rehabilitation therapy program provided in an inpatient rehabilitation facility. The member continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement;however, the documentation doesn't support that she would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the member would require skilled rehabilitation in an IRF, participating in rehabilitationservices fifteenhours perweek, under the supervision of a physician with at least threevisits weekly to regain or maintain her functional status. The member is ambulating up to twenty fivefeet with minimal assistance. She can receive further services at a lower 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-approvean acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents aneed for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.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 haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora neurostimulation procedure provided on September 22, 2020.You asked the Plan to waive the copayment forspecialist service. You say that you appealed to have the copayments for this treatment reduced and it was approved, but now you are being charged the full copayment again.The Plandenied your request. The Plan says the copayment amount you are being charged is correct. The Plan also says that they have reduced your copayment amount from $35 to $30 for this claim.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 $35 copayment for in-network specialist service.You have been asked to pay $30, which is less than the $35 copayment for specialist service. Specialist service 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 fora neurostimulation procedure provided on September 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe functional electrical stimulation (FES) device.You asked the Plan to pre-approvethe functional electrical stimulation (FES) device. You say that you would like reconsideration because without this therapy, your overall health would be of lesser quality.The Plan denied your request. The Plan says there is no documentation supporting that this device is being used with the intention of helping you regain the ability to walk as you are ambulatory.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 functional electrical stimulation (FES) device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the device is being used to achieve walking in a patient with a Spinal Cord Injury (SCI) or that this device is being used for disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse atrophy.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 functional electrical stimulation (FES) devicehave not beenmet.Therefore, we decided that the Plan does not have to pre-approvethe functional electrical stimulation (FES) device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on February 25, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you take these medications daily at home. The Plan denied your request. The Plan says benefits for self-administered drugs are excluded under your plan.
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 for the self-administered drugs provided on February 25, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe one replacement of replaceable part of semi-precision or precision attachment, reline complete mandibular denture, and reline complete maxillary denture provided on July 23, 2020.You asked the Plan to pay forthe one replacement of replaceable part of semi-precision or precision attachment, reline complete mandibular denture, and reline complete maxillary denture. You say that a Plan representative advised you that you had a $1,000 reimbursement for dental services.The Plan denied your request. The Plan says your $150.00 yearly allowance was met, and the claims processed correctly. The Plan also says that no phone calls were found in which you were provided incorrect information about your 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 Plan offers a a $150 allowance every year for Non-Medicare covered preventive and comprehensive dental services combined. The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit on July 23, 2020, and your annual maximum benefit had been exhausted.Therefore, we decided that the Plan does not have to pay forthe one replacement of replaceable part of semi-
precision or precision attachment, reline complete mandibular denture, and reline complete maxillary denture provided on July 23, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 22, 2020 by an out of network (OON) provider.You asked the Plan to pay forpsychotherapy visit. You say that you are appealing with supporting records.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.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 forthe medical services provided on June 22, 2020 by an out ofnetwork (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam rendered on August 14, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services exceeded the benefit limit.
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 a maximum
of 2 oral exams per calendar year.
We looked at the file and the Plan's rules. The file shows that you had a limited oral exam on August 14, 2020.
You previously had an oral exam on January 28, 2020 and January 29, 2020 for which the Plan approved and
paid. The services on August 14, 2020 were your third exam in one calendar year and are not covered by your
supplemental dental benefit or medical benefit. Therefore, we decided that the Plan does not have to pay for the
limited oral exam rendered on August 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3330) and core build up (D2950).
You asked the Plan to pre-approve endodontic therapy and core build up. You say that you need these services
for the crown to be stable. The Plan denied your request. The Plan says these 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 requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
endodontic therapy (D3330) and core build up (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea replacement socket.You asked the Plan to pre-approvethe requested item. The Plan denied your request. The Plan says there is no significant difference noted in measurements requiring a new socket.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 requested item. Our physician reviewer found that you havea left below-the-knee amputation, and a five-pound weight loss. There is no documentation that yourcurrent socket requires replacement due to changes in the residual limb; functional need changes; or irreparable damage or wear/tear due to excessive beneficiary weight or prosthetic demands of beingvery active. Therefore, the requested socket is medically reasonable and necessary at this time.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 requested item have not been met.Therefore, we decided that the Plan does not have to pre-approvea replacement socket.