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

We decided that the Plan does not have to pre-approve core build up at tooth #11 and #18 (D2950), for the enrollee.
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the service is 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. This service is not listed in the enrollee's EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve core build up at tooth #11 and #18 (D2950), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from May 18, 2019 through May 22, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from May 18, 2019 through May 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120), dental cleaning (D1110), bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided on December 5, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you do not have out-of-network 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. Periodic oral evaluation - established patient (D0120), dental cleaning (D1110) and bitewings - four radiographic images (D0274) are not covered because they were provided by an out-of-network provider. Your EOC clearly states, services performed by an out-of-network dentist if your plan does not have out-of-network coverage. Furthermore, intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120), dental cleaning (D1110), bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided on December 5, 2019 by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on July 10, 2019.
You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied your request. The Plan says payment of this service is bundled into other services.
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 95999 is not supported in the medical record. Specifically, theuse of unlisted CPT code 95999 to report train of four testing is not supported. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on July 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided on January 14, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you exhausted your benefit frequency 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. You exhausted your benefit frequency limit, because you had this service on January 6, 2020. Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested varicose vein treatment.
You asked the Plan to pre-approve the varicose vein treatment. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested varicose vein treatment.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) Lung
Cancer Screening (G0297).
You asked the Plan to pre-approve the LDCT Lung Cancer Screening. You say that the Lung Cancer Screening
is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that enrollees must be between 55 and 77 years old to
be eligible for LDCT Lung Cancer Screening.
We looked at the file and Medicare rules. The enrollee does not yet meet the age requirements for coverage.
Based on this information, we decided that Medicare rules for coverage of the LDCT Lung Cancer Screening
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Low Dose Computed
Tomography (LDCT) Lung Cancer Screening (G0297).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on November 7, 2019 by an outof-
network provider.
You asked the Plan to pay for the dental services. You say that you contacted the dental vendor prior to the
services and received the information for the provider. The Plan denied your request. The Plan says you
contacted the dental vendor prior to the services and received the information for the provider.
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 provider is not in-network and your EOC clearly states, supplemental (i.e., routine) dental services must be
received from a participating provider in order to be covered by the plan. Therefore, we decided that the Plan
does not have to pay for the dental services provided on November 7, 2019 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pathology services coded 81479 provided on June 17, 2019.
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 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. In this case, the CPT Code Manual definition of code 81479 is unlisted molecular pathology procedure. We find that CPT code 81479 is not supported in the medical record. Specifically, this code is not covered according to the 2019 Medicare Supplier's Fee Schedule. 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 81479 provided on June 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you would like the Plan to reconsider their denial of the requested orthotics. You say that over the counter orthotics do not work for you. You stated that your left leg is shorter than your right, and you have a joint protruding in your left foot that requires the custom orthotics. You have had two foot surgeries previously and you say that you believe the custom orthotics are medically necessary for you. You do not want to fall or have additional surgery. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana to be provided at a lower cost (tier level).
You asked the Plan to pre-approve Brovana to be provided at a lower cost (tier level). You say that you would like the plan to reconsider their decision. The Plan denied your request. The Plan says tier exceptions are not covered under your Medicare Part B plan.
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 looked at the file and Medicare rules. A tier exception is not covered under your Medicare Part B plan. Tier exceptions only apply to your Part D drugs. Your request is not covered for a tier exception because the drug requested is not covered under Medicare Part D. Based on this information, we decided that Medicare rules for coverage of Brovana to be provided at a lower cost (tier level) have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana to be provided at a lower cost (tier level).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forprogrammingdevice evaluation provided on September 20, 2019 by an out of network (OON) provider.You asked the Plan to pay forprogramming device evaluation. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was 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. ThePlan 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 forprogramming device evaluation provided on September 20,2019 by an out of network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from September 13, 2019 through September 16, 2019.
You asked the Plan to pay for inpatient hospital care. You say that you made every attempt to obtain authorization. The Plan denied your request. The Plan says prior approval was not obtained for non-emergent services rendered in the service area and Good Cause not provided for not obtaining prior approval.
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 inpatient hospital care provided to the enrollee from September 13, 2019 through September 16, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 35 fractions of proton beam therapy.
You asked the Plan to pre-approve 35 fractions of proton beam therapy. 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 35 fractions of proton beam therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found it is not plausible that proton therapy would provide a clinically meaningful benefit over a well-designed IMRT plan. While not experimental, it's potential benefit over non-proton based radiation is an investigational question. Thus, proton therapy is not necessary as it would not meet ASTRO or NCCN criteria and therefore would not be furnished in accordance with accepted standards of care. 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 35 fractions of proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 35 fractions of proton beam therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve to see a non-participating plan provider for tooth extraction.
You asked the Plan to pre-approve the services. You say that you would like a dental tooth extraction with an anesthesiologist. The Plan denied your request. The Plan says this is not a covered benefit and not a plan provider.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. Your dysautonomia and hypotension may require that dental anesthesia should occur within an outpatient surgery center. However, the facility being requested is non-contracted. Since contracted facilities are available for the required services, we are upholding the denial to have services performed at a non-contracted facility as a benefit denial. The anesthesia should be performed at a contracted facility. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve to see a non-participating plan provider for tooth extraction.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forarthrocentesis (CPT 20611) services provided to the enrollee on August 12, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysCurrent Procedural Terminology (CPT) code 20611 remains not supported.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 20611 is "Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting."We asked our coding 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 coded correctly. Our coding reviewer found the medical records provided do not include pemanent recording of images to corroborate the services, therefore,this service cannot be verified.We looked at this coder'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 Plandoes not haveto pay forarthrocentesis (CPT 20611) services provided to the enrollee on August 12, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forSNF care provided to the enrollee from August 26, 2019 through September 23, 2019.You asked the Plan to pay forSNF care. You say that the services should be paid.The Plan denied your request. The Plan says the services should be paid.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from March 26, 2019 through September 28, 2019. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage duringthis benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pay forSNF care provided to the enrollee from August 26, 2019 through September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 27, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe office visit (99214). You say that you would like reconsideration because you were not aware that the member's Plan was a Medicare plan.The Plan denied your request. The Plan says prior authorization was not obtained and is 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 urgentcare 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 atissue. 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 November 27, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services provided from September 10, 2019 through November 4, 2019, from a provider that opted out of Medicare.You asked the Plan to pay forthe dental services. You say that you knew that the provider was not in-network with your plan, but the dentist stated he would submit the claims so youassumed the services would be covered by your out-of-network benefits.The Plan denied your request. The Plan says the provider opted out of the Medicare program.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.You received care from a provider who is not eligible to participate with Medicare. You are responsible for the full amount of the cost of services you received. The Plan determined the second claim incorrectly processed and paid on service at 80% of the allowed amount and denied the other service stating the surgical service was not covered under your plan benefits. This claim processed incorrectly. As this provider has opted out of participating with Medicare, this claim should have been fully rejectedwith no payments being made to the provider. As a courtesy to you the Plan has decided not to reprocess this claim because the claim to process correctly would increase your liability on this claim.Therefore, we decided that the Plan does not have to pay forthe dental services provided from September 10, 2019 through November 4, 2019, from a provider that opted out of Medicare.