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

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), unspecific procedure (D1999), other drugs/medicaments (D9630), intraoral periapical images (D0220), guided tissue regeneration (D4266), tooth extraction (D7210), and bone replacement graft for ridge preservation (D7953) received July 21, 2020 from an out-of-network provider.
You asked the Plan to pay for the dental services (D0140, D1999, D9630, D0220, D4266, D7210, D7953). You say that you were not informed that the provider was out-of-network prior to receiving the requested services, therefore the plan should reimburse you at the in-network rates. The Plan denied your request. The Plan says some of the requested services are not covered under your benefit regardless of whether they were obtained in-network or out-of-network (D1999, D9630, D4266, and D7953), and for covered services you were charged the correct copayment or coinsurance amount, plus the difference between the Plan's allowed amount and what was charged by the out-of-network provider (D0140, D0220, and D7210).
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 either are not among those covered under this benefit or are in excess of those covered by this benefit. The Plan does not cover procedures D1999, D9630, D4266, and D7953, regardless of whether they were obtained in-network or out-of-network. The correct cost share applied to the remaining covered procedures. You have paid a $25 copayment for the limited oral evaluation (D0140) and a $25 copayment for the intraoral periapical images (D0220). You paid 50% coinsurance for the tooth extraction (50% of $92.50 (the plan's allowed amount for this procedure) = $46.25). The plan contract states that you can obtain care from an out-of-network dental provider, but you may pay more for these services.
In addition to the required copayments and coinsurance, you are responsible for the difference between the Plan's allowed amount and the amount charged by the out-of-network provider for the covered services. Therefore, we decided that the Plan does not have to pay for or provide additional payment for the dental services (D0140, D1999, D9630, D0220, D4266, D7210, D7953) received July 21, 2020 from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220),
resin-based composite - two surfaces, anterior (D2331), and unspecified preventive procedure, by report
(D1999) provided December 3, 2020.
You asked the Plan to pay for the x-rays, composite and unspecified preventative procedure. You say that you
were unaware that the provider has opted-out of Medicare. The Plan denied your request. The Plan says since
you received services from a Medicare opt-out provider, 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. The Plan covers the x-rays,
composite and unspecified preventative procedure when the services are provided by a licensed dental provider
who accepts Medicare patients in the United States and has not opted out of Original Medicare.
We looked at the file and Medicare rules. In this case you received services from a dental provider who has
opted out of Medicare. Based on this information, we decided that the Plan's rules for coverage of the x-rays,
composite and unspecified preventative procedure have not been met. Therefore, we decided that the Plan does
not have to pay for the intraoral - periapical first radiographic image (D0220), resin-based composite - two
surfaces, anterior (D2331), and unspecified preventive procedure, by report (D1999) provided December 3,
2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (CPT 99601 and CPT 99602) provided
to the enrollee on August 11, 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 these codes are not valid for Medicare purposes.
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 99601 and 99602 are not supported in the medical record. Specifically, these codes
have a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is
not valid for Medicare purposes. 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 home health services
(CPT 99601 and CPT 99602) provided to the enrollee on August 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area (CPT code 15271 LT- 78, and 15271-LT) provided to the enrollee from October 26, 2020, through November 10, 2020, by an out-of-network provider.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
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 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 physician reviewer found the reviewed documentation indicates that the operative report did not include documentation of an application of a skin substitute graft to the trunk, arms or legs, for a total wound surface area up to 100 sq cm, for the first 25 sq cm or less wound surface area; therefore, this code cannot be verified. The requested service code is not substantiated by the clinical documentation in the medical records submitted for review. Per NCCI Chapter III-A (Introduction): Physicians should report the HCPCS/CPT code that describes the procedure performed to the greatest specificity possible. A HCPCS/CPT code should be reported only if all services described by the code are performed'. In this case, in the narrative of the operative report, the requested CPT code was not documented. Per CPT descriptor & CMS guidelines, require the graft to be secured via the method of the provider's choice (sutures, staples, steri-strips). The skin substitute is fashioned to fit the size and contours of the previously prepared wound bed on the trunk, arms, or legs.
It is then placed over the wound and sutured or stapled into place. As a result, the requested procedure code is not substantiated by the clinical documentation in the operative report submitted for review. Therefore, per CPT descriptor, CPT code 15271-LT-78 cannot be verified. The review has determined that the services are not supported by the medical records. 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 application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area (CPT code 15271 LT- 78, and 15271-LT) provided to the enrollee from October 26, 2020, through November 10, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation and management services (annual wellness visit) received on December 8, 2020.
You asked the Plan to pay for the annual wellness visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received exceed your benefit limit.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. You previously received an AWV on March 4, 2020. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation and management services (annual wellness visit) received on December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

e decided that the Plan does not have to pay forthe dental services provided by an out-of-network provider from April 22, 2019 to December 11,2019.You asked the Plan to pay forout-of-network dental care. You say that you were not able to find an in-network provider when you needed necessary dental care, so you used a provider who was out-of-network.The Plan denied your request. The Plan says dental servicesare not covered when they arereceived from providers who do not participate in the Plan's dental network.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 forthe dental services provided by an out-of-network provider from April 22, 2019 to December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power wheelchair and accessories to be provided by an out-of-network provider.
You asked the Plan to pay for the power wheelchair and accessories. You say that the enrollee has trouble ambulating and desperately needs the device. You say that this is your preferred provider of durable medical equipment. The Plan denied your request. The Plan says services are available 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 the power wheelchair and accessories to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the
enrollee on October 16, 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 is a more appropriate code that should be used to bill the services performed.
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 HCPCS code G0483 is "Drug test(s), definitive, utilizing (1)
drug identification methods able to identify individual drugs and distinguish between structural isomers (but
not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any
type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods
(e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all
samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or
drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations
and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed." 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 supported by the medical records. Our physician reviewer found the
review indicates that the documentation indicates that only 20 drug classes were tested. The records do not
support HCPCS G0483, that 22 or more drug classes were performed. The more appropriate code to use is
HCPCS G0482. 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 drug testing services (HCPCS G0483) provided to the enrollee on October 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for face masks (A9270) with sales tax (S9999) purchased on May 27, 2020.
You asked the Plan to pay for face masks with sales tax. You say that you have a lung condition and have to wear a mask. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment is equipment which can withstand repeated use. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of face masks with sales tax have not been met. Specifically, you have purchased face masks, which do not meet the definition of durable medical equipment. Sales tax is not separately payable. Therefore, we decided that the Plan does not have to pay for face masks (A9270) with sales tax (S9999) purchased on May 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not medically necessary. Our physician reviewer found the submitted records show that you were admitted to the hospital on April 16, 2021 with rib fractures and respiratory failure. You are currently medically stable and tolerating tube feedings. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from November
29, 2020, to November 30, 2020.
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says
inpatient care was not medically reasonable and 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 the acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found that the record did not show that at the time of inpatient admission the
admitting physician reasonably expected that the patient'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 the acute inpatient hospital care have not been met. Therefore, we decided that
the Plan does not have to pay for the acute inpatient hospital care provided from November 29, 2020, to
November 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
You asked the Plan to pre-approve Vertiflex. You say that literature supports the safety, effectiveness, and cost-utility of this treatment. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that this is helpful for treatment of the enrollee's condition.
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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental, more research is needed to show its 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Volara system.
You asked the Plan to pre-approve the requested services. You say that the Volara has greatly improved the enrollee's bronchial drainage. The Plan denied your request. The Plan says the device is considered 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 the requested services. Our physician reviewer found that this system combines continuous positive expiratory pressure, airway oscillation, and nebulized medication. This enrollee has bronchiectasis, allergic bronchopulmonary aspergillosis, and recurrent exacerbations. He was previously prescribed the Vest airway clearance system. There is inadequate evidence to support the effectiveness of the Volara system in the treatment of bronchiectasis in the home setting. It is therefore considered experimental, and not medically necessary. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Volara system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the teeth extractions received from an out-of-network provider.
You asked the Plan to pay for the teeth extractions. You say that the out-of-network provider told you these services would be covered by your insurance. The Plan denied your request. The Plan says your supplemental benefit does not include services received from an out-of-network 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. 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 Evidence of Coverage clearly states that you must pay 100% of the cost for teeth extractions received out-of-network. Therefore, we decided that the Plan does not have to pay for the teeth extractions received from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve transthoracic echocardiography with doppler complete for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to show new, recurrent, or worsening symptoms.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has severe renal disease and will be starting dialysis shortly. He has longstanding hypertension which has required 6 medications to control. Despite this, he has evidence of left ventricular hypertrophy (LVH) on his electrocardiogram (EKG) along with left atrial enlargement. In the setting of episodes of irregular pulse he would be at risk for the development of paroxysmal atrial fibrillation or ventricular ectopy in the setting of LVH. In any event, given the longstanding hypertension and LVH, an assessment of his LV function, the severity of the ventricular wall thickness abnormality, diastolic function abnormalities and a better assessment of left atrial size will be helpful in guiding further medical therapy and managing him once he starts dialysis. This is especially true given the large fluid shifts and hemodynamic instability that may accompany initial dialysis in patients with severe LVH. For a number of reasons, he meets criteria for echocardiography based on the medical necessity and reasonableness indications. 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 been met. Therefore, we decided that the Plan has to pre-approve transthoracic echocardiography with doppler complete for the enrollee.