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

We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), bone replacement
graft for ridge preservation (D7953), and therapeutic parenteral drugs (D9612) provided on August 4, 2020.
You asked the Plan to pay for the guided tissue regeneration, bone replacement graft, and therapeutic parenteral
drugs. You say that your tooth had completely cracked in half and the crown could not be installed. The Plan
denied your request. The Plan says these services are not covered benefits 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
guided tissue regeneration (D4266), bone replacement graft for ridge preservation (D7953), and therapeutic
parenteral drugs (D9612) provided on August 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99222) provided on December 2, 2020.
You asked the Plan to pay for hospital care. You say that this was billed correctly. The Plan denied your request. The Plan says the billed primary diagnosis is not a valid primary diagnosis.
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation.
We looked at the file and Medicare rules. The primary diagnosis on this claim, F05, is a manifestation code. The ICD-10-CM coding convention requires the underlying condition to be billed first. Based on this information, we decided that Medicare rules for coverage of hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99222) provided on December 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for ConfirmMDx testing (81551) provided on March 5, 2021.
You asked the Plan to pay for ConfirmMDx testing. You say that this is a covered benefit. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx is covered for males aged 40 to 85 years old that have undergone a previous cancer-negative prostate biopsy within 24 months and are being considered for a repeat biopsy due to persistent or elevated cancer-risk factors. We looked at the file and Medicare rules. The records do not show that the enrollee was being considered for a repeat biopsy. Based on this information, we decided that Medicare rules for coverage of ConfirmMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for ConfirmMDx testing (81551) provided on March 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the care could be provided through other covered benefits in a different setting to provide a comparable level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for right leg weakness and was diagnosed with a transient ischemic attack. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT of the head or brain (70450) provided on May 18, 2021.
You asked the Plan to pay for the CT of the head or brain. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is a national correct coding initiative edit between CPT code 70450 and 70496,
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, we have confirmed that code the CT of the head or brain has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the CT of the head or brain (70450) provided on May 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment the outpatient knee surgery services you received from May 10, 2021, to May 16, 2021.
You asked the Plan to waive the copayment the outpatient surgery. You say that you depend on insurance to cover all of your costs. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $40 copayment for outpatient surgery.
You have been asked to pay a $40 copayment for the outpatient surgery. 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 the outpatient knee surgery services you received from May 10, 2021, to May 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a porcelain or ceramic crown (D2740) provided on October 28, 2020.
You asked the Plan to pay for a porcelain or ceramic crown. You say that you had to pay this expense out of pocket due to an emergency related to the Coronavirus pandemic. The Plan denied your request. The Plan says the requested 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 service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a porcelain or ceramic crown (D2740) provided on October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on January 26, 2021.
You asked the Plan to pay for an eye refraction. You say that you would like to be paid the amount normally paid for this service had the provider been in-network. The Plan denied your request. The Plan says the service at issue is not a covered benefit when provided by an out-of-network provider. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when it is performed as a routine screening by a participating provider. We looked at the file and the Plan's rules. The records show that the service at issue was provided by an out-of-network provider. This service is not covered by the Plan when provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an unspecified removable prosthodontic procedure (D5899)
provided on June 25, 2021.
You asked the Plan to pay for an unspecified removable prosthodontic procedure. You say that you disagree
with the Plan's denial. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an
unspecified removable prosthodontic procedure (D5899) provided on June 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation 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 the requested service is not supported without two medial branch blocks providing 80% improvement in pain relief.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee has only had one set of diagnostic medial branch blocks and has not undergone prior radiofrequency ablation (RFA) at the same level. There needs to be two diagnostic medial branch blocks that have achieved 80% or more pain relief for the appropriate amount of time. The review has determined that the enrollee does not meet the criteria for the requested procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on May 18, 2021, to May 19, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the doctor recommended admission for pain management and physical therapy. The Plan denied your request. The Plan says the medical records received do not support the need for inpatient care.
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 shows that the enrollee was admitted and evaluated for physical therapy. Our physician reviewer found 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 emergency department 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 not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided on May 18, 2021, to May 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the magnetic resonance angiography (MRA) of the head provided on May 31, 2021, billed with code 70544-26.

You asked the Plan to pay for the MRA interpretation as billed. You say that these should both be payable. The Plan denied your request. The Plan says there is an NCCI edit between the two billed codes and no appropriate modifier was used.

The Plan must follow Medicare rules. Medicare rules say that NCCI edits are organized in a Column I/Column 2 table. Each edit is a pair of codes that should not be reported together. If a provider reports two codes of an edit pair, only the Column 1 code is payable unless an appropriate NCCI modifier is used.

Code 70544 is a Column 2 code in relation to 70551 which was billed on the same date of service. No NCCI modifier was used to justify bypassing the edit. Therefore, we decided that the Plan does not have to pay for the interpretation of the magnetic resonance angiography (MRA) of the head provided on May 31, 2021, billed with code 70544-26.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a filling (D2335) provided on March 23, 2021.
You asked the Plan to pay for a filling. You say that you want the Plan to pay for the service. The Plan denied your request. The Plan says you are not covered for this service when seen by 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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a filling have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. 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 a filling (D2335) provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 2, 2020, by
an out-of-network provider.

You asked the Plan to pay for subsequent nursing facility care (99309). You say that the service was provided
with no adequate time frame to obtain authorization. The Plan denied your request. The Plan says the provider
did not attempt an authorization request for any 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 service at issue in this appeal. The Plan did not pre-approve the service
at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that
the Plan does not have to pay for subsequent nursing facility care provided on June 2, 2020, by an out-ofnetwork
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an electrocardiogram complete (93000) and 
a rhythm electrocardiogram (93042) provided on February 21, 2021, to March 17, 2021. 
 
You asked the Plan to waive the copayment for outpatient procedures. You say that there is a pending payment 
due to the provider. You also say you would like the provider to be paid correctly, so that you can pay the 
remaining balance. The Plan denied your request. The Plan says the copayments you are being charged are 
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 $25 
copayment for each outpatient diagnostic tests and therapeutic services and supplies. 

You have been asked to pay a $25 copayment for each electrocardiogram. The records show that you had a 
rhythm electrocardiogram on February 21, 2021 and February 23, 2021. The EOC confirms that $25 is the 
required copayment for each service. You have been asked to pay a copayment of $6.99 for each, which is less 
than the Plan's contracted amount. The records also show that that you had an electrocardiogram complete on 
March 17, 2021. The EOC confirms $25 is the required copayment for this service; however, you have been 
asked to pay a copayment of $14.97, which is less than the Plan's contracted amount. Electrocardiograms 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 copayment for an electrocardiogram complete (93000) and a rhythm 
electrocardiogram (93042) provided on February 21, 2021, to March 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the MRI, spinal canal and contents, lumbar; without contrast 
material (CPT code 72148 X 5) provided to the enrollee on August 31, 2020. 
 
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 covered 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. 

The enrollee had professional interpretation of the MRI of the lumbar spine, code 72148-26, on August 31, 
2020. The submitted documentation supports 1 (one) unit of 72148-26, which is previously approved as 
documented. There is no additional documentation supporting an additional study which was billed and 
remains denied. 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 the MRI, spinal canal and contents, 
lumbar; without contrast material (CPT code 72148 X 5) provided to the enrollee on August 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says a transport wheelchair was approved.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation does not reveal that you require this scooter to perform MRADLs in the home. Your mobility deficit can be helped with your current group 2 power wheelchair. The documentation does not support a medical need for a replacement of the current wheelchair. You were approved for a transport wheelchair for community use.
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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331) and problem focused limited oral evaluation (D0140) provided on November 24, 2020.

You asked the Plan to pay for the treatment of root canal obstruction and problem focused limited oral evaluation. You say that you were advised that the Plan only paid $208 out of the $319 that was billed by the office. You also say that you had already paid the $111 difference that was due. The Plan denied your request. The Plan says the treatment of root canal obstruction is not a covered benefit under your dental plan. The Plan also says that the problem focused limited oral evaluation exceeds the frequency limitation in your benefit 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, treatment of root canal obstruction (D3331) is not among those covered under this benefit. The contract says that problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on November 14, 2020 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331) and problem focused limited oral evaluation (D0140) provided on November 24, 2020.