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

We decided that the Plan does not have to provide coverage for additional non-emergent routine transportation trips (A0100).

You asked the Plan to provide coverage for additional routine transportation trips. You say that you need additional transportation as you continue care for burns on your right foot and thigh. The Plan denied your request. The Plan says you have exhausted your 2021 benefit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional non-emergent routine transportation trips (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete series of radiographic images (D0210) provided on December 30, 2020.
You asked the Plan to pay for a complete series of radiographic images. You say that you did not want to get the x-ray done because it was not covered by your insurance. You also say the payment arrangement is expensive and you cannot afford it. You would like the Plan to reconsider and pay for the service. The Plan denied your request. The Plan says the service is not covered by the health 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 a complete series of radiographic images (D0210) provided on December 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on March 25, 2021.

You asked the Plan to pay for the psychotherapy services. You say that this should be paid as the services were rendered in good faith. The Plan denied your request. The Plan says there is no evidence of a consultation with the treating physician.

The Plan must follow Medicare rules. Medicare rules say that CPs must attempt to consult with a patient's primary/attending physician and document this attempt.

The record provided makes no indication that the patient's physician was consulted. Therefore, we decided that the Plan does not have to pay for the psychotherapy services provided on March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the upper and lower partial dentures. We decided that the Plan does not have to pre-approve the root canals and crowns.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan says that the services are not covered benefits.
We decided that the Plan has to pre-approve the upper and lower partial dentures.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the dentures are not covered by your supplemental dental benefit; however, the EOC clearly states that "prosthodontics, including dentures," are a covered benefit. The Plan has not provided any further information or documentation to support that the partial dentures are not covered. Therefore, we decided that the Plan has to pre-approve the upper and lower partial dentures.
We also decided that the Plan does not have to pre-approve the root canals and crowns.
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 pre-approve the root canals and crowns.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the criteria for coverage are not met.
The Plan must follow Medicare rules. The rules say that LDCT for lung cancer screening is covered for beneficiaries aged 55 to 77 years who meet specific criteria. We looked at the file and Medicare rules. The file shows that the enrollee is aged 78 years. Based on this 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 pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychology services on February 10, 2021.
You asked the Plan to pay for the psychological services. You say that the physician only rendered medically necessary services in good faith. The Plan denied your request. The Plan says there was no discussion or involvement with the attending or Primary Care Physician.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Specifically, the record shows that the services were provided by a Clinical Psychologist without consultation from the enrollee's Primary Care Physician. There was no referring physician on file. Therefore, we decided that the Plan does not have to pay for the psychology services on February 10, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the esophagogastroduodenoscopy (EGD) procedure provided on July 27, 2021, billed with code 43248.
You asked the Plan to pay for the EGD. You say that these codes are supported. The Plan denied your request. The Plan says the documentation does not include evidence of the performance of an EGD on this date of service.
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 43248 is Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire. We asked our coder 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 EGD. Our reviewer says that the billed code is not supported. Our reviewer found the procedure report documents only a colonoscopy was performed for this date of service. Therefore, CPT 43248 is not supported by the documentation submitted and would not be covered. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the EGD have not been met. Therefore, we decided that the Plan does not have to pay for the esophagogastroduodenoscopy (EGD) procedure provided on July 27, 2021, billed with code 43248.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for grafting of autologous fat harvested by liposuction technique (15771), Peri-implant capsulectomy (19371) and insertion or replacement of breast implant (19342) provided on April 15, 2021.
You asked the Plan to pay for the grafting, capsulectomy and breast implant. You say that you would like reconsideration because these services are not subject to the Medicare Unlikely Edits. The Plan denied your request. The Plan says the billed services do not meet coverage criteria.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. The rules also say that report bilateral surgical procedures on a single claim line with modifier 50 and one (1) unit of service. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) codes 19342 and 19371. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Additionally, CPT code 19342 has a bilateral indicator of one. This claim was not billed with the appropriate bilateral modifier. Based upon this information, we find that Medicare coverage criteria for the grafting, capsulectomy and breast implant have not been met. Therefore, we decided that the Plan does not have to pay for grafting of autologous fat harvested by liposuction technique (15771), Peri-implant capsulectomy (19371) and insertion or replacement of breast implant (19342) provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Asciminib as part of a clinical trial.
You asked the Plan to pre-approve Asciminib as part of a clinical trial. You say that this is medically necessary for the enrollee's medical condition. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve Asciminib as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Asciminib as part of a clinical trial
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (endodontic therapy) for tooth 18 and 20, a porcelain/ceramic pontic for tooth 19, and a porcelain/ceramic retainer crown on tooth 18 and 20.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says 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. 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 pre-approve a root canal (endodontic therapy) for tooth 18 and 20, a porcelain/ceramic pontic for tooth 19, and a porcelain/ceramic retainer crown on tooth 18 and 20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D2740 x2, D0140) received from January 13, 2021, to March 17, 2021.
You asked the Plan to pay for dental services. You say that you were assured that you had coverage. The Plan denied your request. The Plan says you have exhausted the maximum benefit limit of $3,000.
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 dental services with a coverage limit of $3,000 in 2021. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. Specifically, the record shows that you've exhausted the $3,000
benefit limit for services in 2021. Therefore, we decided that the Plan does not have to pay for dental services
(D2740 x2, D0140) received from January 13, 2021, to March 17, 2021
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from May 1, 2019, through May 14, 2019 billed with 13 days of code RHB.
You asked the Plan to pay for the SNF stay as billed. You say that you have submitted all the records that were cited as missing by the Plan's auditor. The Plan denied your request. The Plan says that the audit found that there was a missing 14-day assessment and no documentation of a COT assessment that was required.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has failed to provide a cogent denial rationale that corresponds to the documentation submitted for review by the SNF provider. It is stated that there was no record of a 14-day assessment so only the default rate could be paid for May 10, 2019, to May 14, 2019. However, the documentation submitted with the appeal clearly shows that the provider has included a record of the 14-day assessment which the Plan neglected to review. It is also noted that a COT assessment was required on May 10, 2019, meaning that a lower code would be paid for the other days of the stay. The Plan failed to identify the cause for the need of a COT assessment at this time as there was no citation showing that the total RTM was changing drastically. In fact, the day after the Plan contends this COT assessment was required was when the scheduled 14-day assessment was done. The RAI manual does indicate that if an unscheduled assessment were required around the time of a scheduled one, these assessments would be done as one. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from May 1, 2019, through May 14, 2019 billed with 13 days of code RHB.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the charges for the colonoscopy with polyp removal provided on June 23, 2021.
You asked the Plan to waive the charges for the colonoscopy with polyp removal. You say that you feel that this should be considered routine and be covered with no cost sharing. The Plan denied your request. The Plan says because you had a polyp removed during this procedure, it is considered a diagnostic surgical procedure per Medicare and your EOC. As such, the deductible was correctly 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 $750 deductible for most medical services. The contract does states that outpatient surgery is subject to the deductible and that if a colonoscopy results in a removal of a polyp that it is considered outpatient surgery. You have been asked to pay a $750 deductible for the colonoscopy with polyp removal. The colonoscopy with polyp removal falls within the outpatient surgery 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 charges for the colonoscopy with polyp removal provided on June 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of a spinal cord stimulator (SCS).
You asked the Plan to pre-approve the SCS procedure. You say that it is felt this is necessary to treat the enrollee's pain. The Plan denied your request. The Plan says the records show the enrollee does not have a condition for which this treatment is medically necessary. She has not had physical or psychological therapy to try to help the pain issues.
The Plan follows Medicare rules. Medicare rules say that SCS placement is covered when medically reasonable and 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 SCS procedure. Our reviewer says that the documentation does not support the medical necessity of the SCS. Our physician reviewer found the enrollee has chronic neck and low back pain. She has the diagnosis of Fibromyalgia, Lupus and peripheral neuropathy. She is taking Buprenorphine, cyclobenzaprine, Gabapentin and Tramadol for pain. She also uses Cannabis. She has facet joint hypertrophy on imaging. She has had trigger point injections with some temporary relief and had one set of Medial branch blocks which produced 90% pain relief but has not had a second set or denervation of the facet nerves. The patient does not have an evidence-based indication for SCS placement. She has not had denervation of her facet joints and is not taking medication for her fibromyalgia. The request is not medically reasonable or 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 SCS procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of a spinal cord stimulator (SCS).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyewear services you received on February 17, 2021(V2020, V2303, V2304, V2750).
You asked the Plan to pay for the vision services. You say that you do not understand why you have received a claim for the services rendered. The Plan denied your request. The Plan says you have exceeded the allowable amount of $350 and must pay the difference.
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 the Plan has a $350 allowance for eyewear, but if the purchase costs more than $350 you must pay the difference. We looked at the file and the Plan's rules. The amount of $109 is the amount that the claim exceeded the $350 allowance, which is the enrollee's responsibility. Based on this information, we decided that the Plan's rules for additional coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for eyewear services you received on February 17, 2021(V2020, V2303, V2304, V2750).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit.
You asked the Plan to waive the copayment for an office visit. You say that you were told that this copayment would be $0. The Plan denied your request. The Plan says the copayment applied 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 an office visit with a specialist. You have been asked to pay a $40 copayment for an office visit. This office visit falls within the office visit with a specialist 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 office visit with the provider on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper and lower complete dentures.
You asked the Plan to pre-approve these services. You say that you lost your dentures and need to replace them. The Plan denied your request. The Plan says the request exceeds the benefit limit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers complete dentures once every five plan years. We looked at the file and the Plan's rules. The file shows that you previously received complete dentures on September 22, 2020 for which the Plan approved and covered. You are not eligible for new dentures until five years after this date. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve upper and lower complete dentures.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electro-acupuncture device.
You asked the Plan to pre-approve these services. You say that The Plan denied your request. The Plan says the services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the Plan covers acupuncture only for the treatment of low back pain. The file shows that the requested device is not for the treatment of low back pain. Therefore, we decided that the Plan does not have to pre-approve an electro-acupuncture device.