Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 3, 2021.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
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 99214 is not supported in the medical record. Specifically, this code was billed wit place of service 12 (home). This is an incorrect place of service for this code. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit provided on February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6240) for tooth #7 and retainer crowns
(D6750) for tooth #'s 6 and 8.
You asked the Plan to pre-approve the pontic and retainer crowns. You say that you really need these services
to be approved for coverage. The Plan denied your request. The Plan says these services are not medically
necessary.
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 pontic and
retainer crowns when the services are medically necessary and reasonable.
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 pontic and retainer crowns. Our reviewer says that the pontic and retainer crowns are not medically necessary. Our physician reviewer found
you are missing tooth #'s 1, 2, 3, 4, 6, 12, 13, 14, 15, and 16 in the upper arch. The requested bridge appears to
be incorrectly coded as tooth #'s 5 and 7 are present in the upper arch and tooth #6 was noted as having been removed in June 2021. Our reviewer found that as the request stands the claim is in error. In any event, even a bridge replacing tooth #6 would not meet Plan criteria. Our physician reviewer also found that in this instance, as there are multiple missing posterior teeth in the arch, the criteria is not met under the Plan and there is no necessity for the requested procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the pontic and retainer crowns have not been met. Therefore, we decided that
the Plan does not have to pre-approve a pontic (D6240) for tooth #7 and retainer crowns (D6750) for tooth #'s 6
and 8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the localized deliveries of antimicrobial agents (D4381) and gingival irrigations (D4921) provided on December 22, 2020.
You asked the Plan to pay for the localized deliveries of antimicrobial agents and gingival irrigations. You say that you would like the enrollee to be refunded all but the $45 copay. 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 pay for the localized deliveries of antimicrobial agents (D4381) and gingival irrigations (D4921) provided on December 22, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department visit for the evaluation and
management of a patient, which requires these 3 key components within the constraints imposed by the
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive
examination; and Medical decision making of high complexity (99285) provided November 12, 2020.
You asked the Plan to pay for the emergency department visit. You say that please review the attached
supporting documentation as the services have been deemed payable. The Plan denied your request. The Plan
says the records do not support the high level of complexity billed under CPT code 99285.
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect
the services provided.
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the
evaluation and management of a patient which requires three components (taking into account the urgency of
the clinical condition or the patient's mental status):
1. a comprehensive history;
2. a comprehensive examination; and
3. medical decision making of high complexity.
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate
significant threat to life or physiologic function.
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 emergency department visit Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our reviewer found based on the presentation and treatments administered for this patient in the ED, there
was no evidence of moderate complexity or of urgency besides her high blood pressure, which was of low
complexity and severity as there was no signs of end-organ damage. Therefore, the code, 99285, was not
sufficiently supported by the provided 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 emergency department visit have not been met. Therefore, we decided that
the Plan does not have to pay for emergency department visit for the evaluation and management of a patient,
which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical
condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision
making of high complexity (99285) provided November 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 30, 2020, to February
13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you were referred to this provider. You say that
you would like the Plan to pay for this. The Plan denied your request. The Plan says you have no out-ofnetwork
benefits. The Plan says that there are in-network providers who could have provided 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 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 physician services provided on January 30, 2020,
to February 13, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care (99291) and electrocardiogram (99291) provided December 23, 2020.
You asked the Plan to pay for the critical care and electrocardiogram. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says they received incomplete or incorrect documentation for the services provided.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the critical care and electrocardiogram. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the claim for the services provided by the provider on December 23, 2020 were processed correctly. Incomplete or incorrect documentation was received for review. Medical records are still needed to support the service Current Procedural Terminology (CPT) codes 99291, critical care, and 93010, electrocardiogram, on date of service December 23, 2020. The review has determined that the medical records provided do not support that the items/services at issue in this case were medically reasonable and 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 critical care and electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for the critical care (99291) and electrocardiogram (99291) provided December 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vasectomy.
You asked the Plan to pre-approve a vasectomy. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a vasectomy is not covered if the primary indication for these procedures is sterilization. We looked at the file and Medicare rules. In this case, the primary reason for the requested vasectomy is sterilization. This is not a covered indicator for this procedure. Based on this information, we decided that Medicare rules for coverage of a vasectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a vasectomy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), the periapical x-ray (D0220), the unspecified preventive service (D1999), and the sales tax (D9985) provided on November 10, 2020.
You asked the Plan to reimburse you for the dental services. You say that the services you received were an emergency. You say that you were suffering from severe, incapacitating pain which prevented you from eating or drinking anything other than water. You also say that the care you received was not routine or cosmetic. The Plan denied your request. The Plan says the dental services performed are routine in nature. The Plan also says that routine dental services are not covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), the periapical x-ray (D0220), the unspecified preventive service (D1999), and the sales tax (D9985) provided on November 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the bitewing x-rays (D0274) provided on December 29, 2020.
You asked the Plan to pay for the dental services. You say that you called before your appointments to make sure that they were covered. You say that you were informed that they were. You say that you were told you cleanings are covered twice a year and you went twice within the year. Yous ay that The Plan denied your request. The Plan says oral exams are covered once every 6 months. The Plan says that dental x-rays are covered every 12 months. The Plan also says that the frequency limits have been exceeded for these services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for an oral exam and bitewing x-rays that you received on October 9, 2020, less than 6 months before. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the bitewing x-rays (D0274) provided on December 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site
(D7953), the guided tissue regeneration - resorbable barrier, per site (D4266) and the inhalation of nitrous
oxide/analgesia, anxiolysis (D9230) received March 11, 2021.
You asked the Plan to pay for the dental services. You say that you would not have received these procedures if
you knew they were not covered. The Plan denied your request. The Plan says the requested services are not
covered under your supplemental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone
replacement graft for ridge preservation - per site (D7953), the guided tissue regeneration - resorbable barrier,
per site (D4266) and the inhalation of nitrous oxide/analgesia, anxiolysis (D9230) received March 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two services performed by a qualified physical therapist in the home health or hospice setting (G0151 x2).
You asked the Plan to pre-approve the services performed by a qualified physical therapist. You say that the enrollee needs assistance with her activities of daily living and instrumental activities of daily living. The Plan denied your request. The Plan says skilled physical therapy is not medically necessary at this time.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 performed by a qualified
physical therapist. Our reviewer says that ongoing home health physical therapy services are not medically
necessary or reasonable. Our physician reviewer found the enrollee does not have documented skilled therapy
needs. Our reviewer also found that the enrollee appears to have reached a plateau in funct ion.
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 performed by a qualified physical therapist have not been met.
Therefore, we decided that the Plan does not have to pre-approve two services performed by a qualified
physical therapist in the home health or hospice setting (G0151 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), preventive procedure (D1999), and extraction (D7210) provided on November 10, 2020.
You asked the Plan to pay for the comprehensive oral evaluation, preventive procedure, and extraction. You say that the care you received was not routine or cosmetic dentistry, but treatment of a serious illness. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), preventive procedure (D1999), and extraction (D7210) provided on November 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission for total hip arthroplasty.
You asked the Plan to pre-approve inpatient admission. The Plan denied your request. The Plan says inpatient admission 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 inpatient admission. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that detailed documentation is not evident regarding significant co-morbidities or past medical history that would require a need for pre-authorization of inpatient hospital stay. There is limited published, large-scale, long-term peer-reviewed literature that shows a pre-scheduled inpatient stay after total hip arthroplasty is any more beneficial than performing the procedure outpatient. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission for total hip arthroplasty.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ECG's provided from March 10, 2021, to
April 13, 2021.
You asked the Plan to waive the copayments for ECG's. You say that you have never been charged in the past
and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly
and you are being charged the correct amount.
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 $30
copayment for each diagnostic procedure or test.
You received ECG's from March 10, 2021, to April 13, 2021, for a total of 3 services. Therefore, you are
responsible to pay the total allowed amount of $58.38, which is less than the total copayment amount.
You have been asked to pay the total copayment amount of $58.38 for ECG's. ECG's fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for ECG's provided from March 10, 2021, to April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on April 17, 2021 by an out of network (OON) provider.
You asked the Plan to pay for outpatient services. You say that you believe it is the hospital's responsibility to obtain prior authorization for these services. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that these services were not rendered in a participating facility.
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 outpatient services provided on April 17, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services provided on January 29, 2021 by an out of network (OON) provider.
You asked the Plan to pay for pain management services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says this provider is not a network provider. The Plan says that services were not referred by a network provider or rendered in a participating facility.
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 pain management
services provided on January 29, 2021 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on December 9, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting medical records.
The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the
documentation does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).
The documentation shows that the sample for this testing was taken in an office setting. Therefore, the POS
code 81 - indicating an independent lab setting - is not appropriate for this claim. Therefore, we decided that
the Plan does not have to pay for genetic testing provided on December 9, 2020.