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

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on March 26, 2020.
You asked the Plan to pay for the first intraoral periapical x-ray. You say that this service was not an elective procedure. You also say that you contacted the Plan and were advised that the Plan would pay the provider the same amount as they would pay an in-network provider, and you would be responsible for the balance. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on March 26, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care rendered from December 25, 2019 to December 28, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services were 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 services meet the criteria for coverage. Our physician reviewer found the enrollee was admitted to the hospital with increased abdominal pain. She had worsening ascites, causing severe abdominal pain, with nausea and vomiting. Plans for a procedure were complicated by a new finding of a thrombus that developed on her portal vein, requiring input from oncology on how to proceed in regards to anticoagulation. The records support that, at the time of the inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 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 rendered from December 25, 2019 to December 28, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex interspinous spacer for the enrollee.
You asked the Plan to pre-approve the spacer. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not shown that this device is helpful for treatment of this health problem.
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 spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental, and more research is needed to show safety and efficacy. 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 spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex interspinous spacer for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care discharge services coded 99217, the initial observation services coded 99218, and the subsequent observation care services coded 99226 provided from December 11, 2019 to December 13, 2019.
You asked the Plan to pay for the observation care discharge services, the initial observation services, and the subsequent observation care 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. We find that CPT codes 99217, 99218, and 99226 are not supported in the medical record. Specifically, the documentation supports that the enrollee was inpatient at the hospital for these dates of service. Since the enrollee was inpatient status, observation services cannot be verified or paid. Based on this information, we decided that Medicare rules for coverage of the observation care discharge services, the initial observation services, and the subsequent observation care services have not been met. Therefore, we decided that the Plan does not have to pay for the observation care discharge services coded 99217, the initial observation services coded 99218, and the subsequent observation care services coded 99226 provided from December 11, 2019 to December 13, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve outpatient skin removal surgery.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says that the extra skin does not hang below the pubic area.
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the requested surgery is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a symptomatic lower hanging abdominal pannus. This has caused chronic rashes. These have been treated unsuccessfully with typical dermatologic management, including prescription medication. The pannus appears to hang below the level of the pubis from review of the photographs. Based on Medicare criteria, panniculectomy should be considered medically necessary. She has a symptomatic lower abdominal pannus treated with appropriate dermatologic management over a greater than 3 month period. Photographs appear to show that the pannus obscures the pubic region. Therefore, panniculectomy satisfies Medicare medically necessary criteria. 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 surgery have been met. Therefore, we decided that the Plan has to pre-approve outpatient skin removal surgery.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

The rules say that plans must pay fora medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes exams and prophylaxis, and are each limited to one procedure per calendar year. You can find this information on page 92 of the Plan's 2019 Evidence of Coverage (EOC).Explanation of decisionWe decided that the Plan does not have to pay forthe periodic oralevaluation and prophylaxis provided on November 12, 2019.You asked the Plan to pay forthe periodic oral evaluation and prophylaxis. You say that you went to the dentist due to pain in a lower molar, and you did not want to wait until it became anemergency. You also say that the provider was not able to find the source of the problem.The Plan denied your request. The Plan says the benefits for these services had been satisfied and the frequency limitations had 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, exams and prophylaxis are each limited to one procedure per calendar year. The record shows that you received a periodic oral evaluation and prophylaxis on March 26, 2019 and your exams and prophylaxis benefits were then exhausted.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation and prophylaxis provided on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on March 5, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
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 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 medical services provided to the enrollee by an out-of-network provider on March 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 26, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the battery (E1399). You say that you would like reconsideration because you were not aware that prior authorization was necessary. The Plan denied your request. The Plan says prior authorization is required to receive services from non-contracted providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on March 26, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray provided March 19, 2020.
You asked the Plan to pay for the intraoral x-ray. You say that you had x-rays and cleanings before and have never been billed. You say that the claim should be paid. The Plan denied your request. The Plan says the service 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.

The records show that you are only responsible for the intraoral x-ray. Therefore, we decided that the Plan does not have to pay for the intraoral x-ray provided March 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a
participating provider on October 30, 2019 to November 10, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with
this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175
copayment for inpatient hospital care/in-network.
You have been asked to pay a $175 copayment for an inpatient hospital stay. The total amount you are being
asked to pay is $1,225 ($175 x 7 days = $1,225). An inpatient hospital stay falls within the inpatient hospital
care/in-network 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 an inpatient hospital
stay provided by a participating provider on October 30, 2019 to November 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.
You asked the Plan to pre-approve a raised toilet seat. You say that the enrollee is 91 years old with right knee pain. She has difficulty getting in and out of a chair and the toilet especially. She needs the toilet seat. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate for the enrollee, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet ablation of a part of the lumbar spine.You asked the Plan to pre-approve facet ablation of a part of the lumbar spine. 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 follows Medicare rules. Medicare rules say that for each covered spinal region (cervical/thoracic or lumbar), no more than two (2) thermal RF sessions will be reimbursed in any rolling 12 month year, involving no more than four (4) joints per session, e.g., two (2) bilateral levels or four (4) unilateral levels.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 facet ablation of a part of the lumbar spine. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has exceeded the number of allowable RF treatments per year. Medical records do not support more than allowable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet ablation of a part of the lumbar spine have not been met.Therefore, we decided that the Plan does not have to pre-approve facet ablation of a part of the lumbar spine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from December 26, 2019 to January 2, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you already paid the invoice and should not owe the copayment amount again. The Plan denied your request. The Plan says the copayment amount you paid was correct.
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 $290 copayment for per day, days 1 to 5 at an in-network, inpatient hospital. You have paid a $1,450 copayment for the inpatient hospital stay. ($290 x 5 days = $1,450). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The record shows you paid the copayment and do not owe the second bill.
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 inpatient hospital stay provided from December 26, 2019 to January 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the out of network IRF services. You say that you want to go to an IRF instead of a nursing home because of COVID-19. The Plan denied your request. The Plan says there are 12 in-network IRF facility within a 20-mile radius of your zip code.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve out of network services. Therefore, we decided that the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network neurosurgeon.You asked the Plan to pre-approvethese services. You say that you filed a grievance in regard to two in-network providers.The Plan denied your request. The Plan says the services are available from network providers.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 items/services at issue in this appeal. The Plan confirmed that they have providers that you have not previously seen that are qualified to evaluate and treat your condition. 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-approvea referral to an out-of-network neurosurgeon.Your complaint  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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe critical care services rendered on November 27, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99292 is 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 99292 is critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service).We find that CPT code 99292 is not supported in the medical record. Specifically, the records document 45 minutes of critical care time and no documentation of an additional 30 minutes of critical care time. Based onthis information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe critical care services rendered on November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on December 26, 2019.You asked the Plan to pay for train of four testing. You say that this should be manually processed.The Plan denied your request. The Plan says this is not separately 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 95999 is not supported in the medical record.  Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other intraoperative neuromonitoring procedures. 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 December 26, 2019.